Expanding Access to GLP-1s in Medicare and Medicaid: CMS Initiatives, the BALANCE Model, and Implications for Beneficiaries and Budgets

The Centers for Medicare & Medicaid Services (CMS) has announced a new voluntary test of a model designed to expand access to GLP-1 medications for weight management and metabolic health improvement while helping control costs for patients and taxpayers.

The Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) Model builds on emerging evidence that combines access to GLP-1 medications with evidence-based lifestyle supports to achieve better long-term health outcomes. Under the model, CMS negotiates directly with pharmaceutical manufacturers of GLP-1 drugs for lower net prices and standardized coverage terms.

Negotiation areas include guaranteed net pricing and potential out-of-pocket limits for beneficiaries, standardized coverage criteria, and evidence-based lifestyle support offerings. The model aims to increase access to select GLP-1 medications and healthy lifestyle interventions to help people with Medicare and Medicaid improve their health.

State Medicaid agencies can apply to participate in the model through the State Request for Applications and can join the model beginning in May 2026 through January 1, 2027. CMS will provide eligible Medicare Part D beneficiaries with access to certain GLP-1 drugs through the Medicare GLP-1 Bridge from July 1, 2026, to December 31, 2027.

According to KFF polling, about half (56%) of GLP-1 users say these drugs were difficult to afford, including one in four who say they were “very difficult” to afford. GLP-1s, a class of drugs used to treat type 2 diabetes, obesity, cardiovascular disease, and other conditions, have exploded in popularity in recent years due to their demonstrated effectiveness but are often not covered by insurance, particularly for the treatment of obesity.

The Trump administration is pursuing various approaches to lowering the cost and expanding coverage of these medications. These approaches include striking “most-favored nation” deals with GLP-1 manufacturers Novo Nordisk and Eli Lilly, providing access to discounted prices for GLP-1s through TrumpRx, and implementing the BALANCE Model to expand Medicare and Medicaid coverage of GLP-1s for obesity, which is currently subject to statutory limitations (prohibited in Medicare, permissible but not required in Medicaid).

the GLP-1 drug semaglutide (branded as Ozempic, Wegovy, and Rybelsus) was selected for Medicare drug price negotiation in 2025, with a negotiated price set to take effect in 2027.

The BALANCE Model represents a major step toward potential expanded access and affordability for millions of Americans. As stated by CMS Administrator Dr. Mehmet Oz, “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.”

These actions further the administration’s bold plan to reform the country’s health systems and Make America Healthy Again. With the BALANCE Model, CMS is pairing breakthrough science with healthy living to cut costs while empowering Americans to take control of their health.