CMS unveils BALANCE program, expands Medicaid and Medicare GLP 1 access

The Centers for Medicare and Medicaid Services announced on December 23 that it will test a voluntary program intended to expand coverage of GLP 1 medications for weight management, obesity and metabolic disease prevention through participating state Medicaid programs and Medicare Part D plans. Named the BALANCE Model, the initiative aims to pair drug access with standardized coverage criteria and funded lifestyle supports while negotiating guaranteed net prices with manufacturers to control costs.

CMS said the model will begin in Medicaid as early as May 2026 and in Medicare Part D in January 2027. To bridge the gap, the agency will also launch a short term GLP 1 payment model in July 2026 to allow beneficiaries to access lower prices before the full BALANCE Model takes effect. Participation by manufacturers, state Medicaid agencies and Part D plans is voluntary. CMS has issued a Request for Applications to manufacturers and notices of intent for states and Part D plans, with all submissions due January 8, 2026. The agency said more details on participants and terms will be released in early 2026.

Under the BALANCE framework, CMS intends to negotiate directly with manufacturers for guaranteed net pricing, potential out of pocket limits for patients, standardized coverage rules and the bundling of evidence based lifestyle and nutrition supports. The Centers for Medicare and Medicaid Innovation will evaluate the program on cost, patient adherence, clinical outcomes and beneficiary experience to determine whether it improves population health and produces savings for taxpayers.

The announcement builds on a November agreement between the federal government and manufacturers Eli Lilly and Novo Nordisk that set a price of one hundred and forty nine dollars per month for certain doses of commonly used GLP 1 medicines for government programs and for cash payers. CMS made clear, however, that final guaranteed net prices, a comprehensive beneficiary eligibility list and a roster of participating manufacturers will be determined through the application and negotiation processes and are not yet public.

Public health experts and advocates say the program could expand access for people who have historically been excluded from obesity treatments, particularly Medicaid enrollees who face higher rates of obesity and related chronic disease. Broader coverage paired with lifestyle supports could yield long term reductions in diabetes and cardiovascular disease, especially in communities of color and low income neighborhoods where these conditions are concentrated.

At the same time, the voluntary nature of the test leaves open the possibility of uneven access across states and Part D plans. States that opt out, or manufacturers that decline to participate, could produce a patchwork of coverage that perpetuates disparities. Policymakers will be watching the Innovation Center evaluation closely for evidence on health outcomes and fiscal sustainability before deciding whether to extend the approach.

As CMS moves to implement BALANCE, operational questions remain about who will be eligible, which manufacturers will join, and how much beneficiaries will ultimately pay. Those answers will determine whether the program delivers meaningful equity gains or simply reshuffles costs within the health care system.