Originally published on 12/24/25

Major Medicare and Medicaid changes are on their way now that the Centers for Medicare & Medicaid Services (CMS) has announced the new Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) model, something that they claim will cut the cost of certain GLP-1 medications for people on the government-funded insurance program. This move comes after President Donald Trump promised to do the same thing on his direct-to-consumer sales program TrumpRx—something that is reportedly different from the BALANCE model—and is expected to impact millions of Americans beginning in the new year. To learn more about the new BALANCE model, including who qualifies for it, keep reading. 

What we know so far about the new Medicare BALANCE model

Under the newly announced BALANCE model and the associated administration deals, eligible Medicare and Medicaid beneficiaries are expected to pay a flat $50 monthly copay for injectable GLP-1 medications like Wegovy and Zepbound.

Estimated out-of-pocket costs

• Medicare Part D: Eligible beneficiaries will pay $50 per month for a 30-day supply.
• Medicaid: Costs for Medicaid patients may be even lower, with some reports indicating they could pay nothing or very minimal amounts, though exact state-specific details are still being finalized through the opt-in process.
• Oral GLP-1s: If oral (pill-form) versions of these drugs are approved by the FDA, starting doses are expected to cost beneficiaries approximately $149–$150 per month.

Comparison to current pricing

The new model represents a significant reduction from current out-of-pocket expenses:

• Previous costs: Without this coverage, patients often paid over $1,000 per month for these medications.
• Government negotiated price: The price the government pays to drugmakers (Eli Lilly and Novo Nordisk) will be reduced to $245 per month for injectables, which is less than half the previous list prices.

Implementation timeline

The savings will not be immediate for all beneficiaries:

• Medicaid: Implementation can begin as early as May 2026 for participating states.
• Medicare Bridge Program: A temporary payment demonstration is planned for July 2026 to provide access before the full model launch.
• Full BALANCE launch: The model is scheduled to officially launch for Medicare Part D in January 2027.

For more information, you can view the official CMS BALANCE Model Fact Sheet.

“Today’s announcement builds upon our historic Most Favored Nations drug pricing deals’ goal of democratizing access to weight-loss medication, which has been out of reach for so many in need,” CMS Administrator Mehmet Oz, MD, said in a statement. “These actions further the administration’s bold plan to reform our country’s health systems and Make America Healthy Again. With the BALANCE Model, we’re pairing breakthrough science with healthy living to cut costs while empowering Americans to take control of their health.”

As of publication, the CMS has not shared what GLP-1 drugs will be available on the government insurance. They did however, share that to lower the price of the medications, they plan to negotiate directly with pharmaceutical manufacturers on things like out-of-pocket limits for beneficiaries and standardized coverage criteria. 

“The BALANCE Model will empower more Americans to live healthier lives by expanding access to GLP-1s that have shown to be a powerful tool against the development of diseases, such as diabetes, cardiovascular disease and other metabolic conditions, which can negatively affect a person’s long-term health,” CMS Innovation Center Director Abe Sutton said in a statement. “Through this model, CMS will make GLP-1s more accessible for people with Medicare and Medicaid.”

How to qualify for the new Medicare BALANCE model

In a press release, the CMS made it clear that participation in the BALANCE model is voluntary for manufacturers, states and plans. The organization plans to release more information in early 2026 regarding state and Part D plan participation. 

Following that, they expect to launch the BALANCE Model for people on Medicaid in May 2026. People on Medicare Part D however, will have to wait until January 2027. 

Currently, there is no information available on how much the BALANCE Model will cost insurers, something that The Alliance of Community Health Plans (ACHP) is worried about. 

“We appreciate the Administration’s commitment to this approach in the aptly named, voluntary BALANCE coverage model for GLP-1s in Medicare and Medicaid. We are eager to see additional details, including the cost to health plans,” the organization said in a statement. “ACHP looks forward to working with the Administration on weight loss therapies that deliver the right treatment, at the right time, at an affordable price.”

Link to original: https://www.womansworld.com/healthcare/medicare-balance-program