BALANCE is set to roll out in Medicaid as early as May 2026 and in Medicare Part D in January 2027, with a bridge period through July 2026 offering eligible Part D enrollees a $50 per month payment.

Participation in BALANCE remains voluntary for drug manufacturers, state Medicaid agencies, and Medicare Part D plans.

The BALANCE model was introduced on December 23, 2025, as a voluntary program letting Medicare Part D plans and state Medicaid agencies cover GLP-1 therapies for weight management and metabolic health.

CMS Innovation Center Director and CMS Administrator highlighted that BALANCE aims to expand access while containing costs.

Historically, proposals have varied between reclassifying obesity as a chronic disease and negotiating price reductions, with BALANCE emphasizing cost-neutral expansion via price reductions.

CMS leadership emphasized broadening access to GLP-1s for diabetes, cardiovascular, and metabolic conditions, while negotiations will address out-of-pocket limits and standardized coverage criteria.

Industry stakeholders, including The Alliance of Community Health Plans, urged caution on unknown insurer costs and called for more details on affordability and implementation.

Under BALANCE, CMS will negotiate lower prices and uniform coverage terms with manufacturers, aiming for guaranteed pricing, possible price caps, standardized eligibility, and inclusion of lifestyle support programs.

About 70% of U.S. adults are overweight or obese, underscoring the potential public health impact of wider GLP-1 access.

BALANCE seeks to improve access and contain costs for patients and taxpayers with nationwide coverage alignment.

Eligibility targets obesity-related conditions such as prediabetes, cardiovascular disease, diabetes, uncontrolled hypertension, and severe obesity, with roughly 10% of Medicare enrollees potentially eligible.

Compared with current pricing, BALANCE could reduce monthly costs from over $1,000 to much lower levels, with government-negotiated injectables around $245 per month.