CMS kicks off GLP-1 model

 CMS shared plans Dec. 23 for its voluntary “Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth” — or BALANCE — model.

The announcement comes weeks following the White House’s agreements with Eli Lilly and Novo Nordisk to apply most-favored-nation pricing for drugs that treat obesity, diabetes and related conditions.

“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 news release.

Here are six notes on the model:

1. CMS will negotiate reduced prices with GLP-1 manufacturers for state Medicaid programs and Medicare Part D plans. Eligible manufacturers must have a product that is any combination of GIP, GLP‐1 and glucagon receptor agonist with an FDA-approved active ingredient for weight management. The drug must be proven to reduce body weight by at least 10% on average.

2. The model will also supplement with “lifestyle support programs” at no cost, such as by encouraging beneficiaries to embrace lower-calorie diets and increased physical activity.

3. Part D sponsors are eligible to participate in the model, along with any states in the Medicaid drug rebate program.

4. Weight-loss coverage will begin in May 2026 for Medicaid and January 2027 for Medicare Part D. A bridge program will enable GLP-1 access for Medicare Part D by July 2026.

5. Those who already qualify for a GLP-1 may be able to access that drug at a reduced price through the model.

6. Interested participants should respond to CMS by Jan. 8, 2026.

https://www.beckerspayer.com/pharmacy/cms-kicks-off-glp-1-model-6-notes/