The Trump administration is now testing a new pricing model, The Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) model. This design more specifically outlines how pricing negotiations will work between the Centers for Medicare & Medicaid Services (CMS) and weight loss drug manufacturers.
Your clients that qualify could benefit from reduced GLP-1 pricing as soon as mid-2026!
What Is the CMS BALANCE Model?
The BALANCE model is a program that will allow CMS to negotiate the following directly with participating GLP-1 drug manufacturers:
- Guaranteed net pricing and potential out-of-pocket limits for beneficiaries
- Standardized coverage criteria
- Evidence-based lifestyle support offerings
Drug manufacturers, states, and insurers can opt into the program; participation is voluntary.
CMS’ GENEROUS Pricing Model vs. the New BALANCE Model
Previously, we reported the groundbreaking developments related to GLP-1 pricing negotiations under the GENErating cost Reductions fOr U.S. Medicaid (GENEROUS) model. These negotiations with pharmaceutical companies, Eli Lilly and Novo Nordisk, were the first steps to more affordable weight loss drugs for beneficiaries.
This pricing model established an opt-in program for state Medicaid programs to offer GLP-1 coverage to eligible individuals under the new pricing agreements. Additionally, this model created a pathway for Medicare beneficiaries to acquire low-cost GLP-1 drugs through a three-phase program. The new BALANCE model seeks to build upon and refine this original model.
Medicaid Beneficiaries’ Access to Lower-Priced GLP-1s
Similar to the GENEROUS model, it’s unclear how many beneficiaries would be able to access more affordable weight loss drugs. Participation in both models is optional for state Medicaid programs.
If a beneficiary meets eligibility criteria and resides in a state whose Medicaid program has selected to participate in the program, they could receive low-cost GLP-1 medications as early as July 2026.
State Medicaid agencies can begin enrolling in the pricing model in May 2026. The testing for this pricing model will conclude in December 2031.
Part D Clients’ Access to Affordable GLP-1s
Eligible Part D beneficiaries will pay $50 per month for GLP-1 medications under the Trump administration’s new BALANCE model.
Beginning July 2026, select Part D beneficiaries could have access to lower-priced GLP-1 medications. At this time, CMS mentions that this temporary program, “Depend[s] on participation by drug manufacturers, states or Part D sponsors. Patients would be subject to qualifications set by the negotiations, including certain prior authorization requirements. Therefore, this model will not guarantee coverage for any individual.”
The GENEROUS model acts as a bridge for affordable prescriptions until the BALANCE model is active in January 2027 for Part D beneficiaries enrolled in a prescription drug plan or Medicare Advantage Prescription Drug plan. These new pricing negotiations will include Special Needs Plans.
CMS also mentions that Part D carriers will not carry risk associated with offering GLP-1 medications at a lower cost to beneficiaries. These reduced prices are negotiated between CMS and drug manufacturers themselves. More information is to come from CMS regarding the design and implementation of this program.
Stay connected with Ritter for more updates regarding the BALANCE pricing model and implementation!
Resources and Support Outside of GLP-1 Medication
In addition, CMS also announced lifestyle programs to support beneficiaries. Any beneficiary being treated for obesity or one of the related conditions with a GLP-1 will have access to the new lifestyle intervention.
These support programs will be provided by the drug manufacturer at no additional cost to your client.
More specific guidelines in place that empower your clients to access affordable weight loss medications means you can empower your clients to speak to their providers if they’re interested in this program! We’re optimistic that this pricing model could lead to more affordable prescriptions for beneficiaries and better health outcomes.
Register with Ritter to get started with Part D and Medicare Advantage carriers that could participate in this pricing model. We’re here to support you through your entire selling journey with our reputable Sales team!
Not affiliated with or endorsed by Medicare or any government agency.
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