Overview
- CMS will negotiate reduced prices with GLP-1 manufacturers for state Medicaid programs and Medicare Part D plans under the BALANCE model.
- State Medicaid agencies can join in May 2026, a temporary bridge will allow Medicare access by July 2026, and Part D participation begins January 2027, with the test running through December 2031.
- An administration agreement would set eligible Medicare enrollees’ monthly payment at $50 for certain GLP-1s, with Medicare paying a larger negotiated amount.
- To qualify, products must include approved GIP/GLP-1/glucagon receptor agonist components and demonstrate at least a 10% average reduction in body weight.
- Participation is voluntary for manufacturers, states, and Part D plans, with notices of intent due by January 8, 2026, and stakeholder groups urging clarity on costs and safety given concerns about side effects and adherence.