CMS issues BALANCE implementation details naming Zepbound and Mounjaro
Lilly says Medicare Part D plans joining CMS's BALANCE model will cap most patients' tirzepatide costs at $50 a month starting January 1, 2027 — but CMS's own page later said BALANCE is not launching in Medicare in 2027.
On March 9, 2026, Eli Lilly said the Centers for Medicare & Medicaid Services had released new implementation details for the CMS Innovation Center's BALANCE model, and that beginning January 1, 2027, Zepbound (tirzepatide), Mounjaro (tirzepatide) and orforglipron, if approved, would be available through participating Medicare Part D plans [1].
Under the terms Lilly described, most beneficiaries in participating plans would pay no more than $50 per month out of pocket once they meet their deductible [1]. Before the deductible is met, cost sharing would be limited to $245 per month plus a dispensing fee [1]. Lilly cautioned that while most Medicare plan options would honor the $50 cap, cost sharing "will vary for beneficiaries in a small number of basic Medicare Part D plans," and said it would work to educate patients and physicians about plan options and smoothing programs [1].
On the Medicaid side, Lilly said state Medicaid programs could apply to participate beginning May 1, 2026, with a rolling start [1]. CMS's BALANCE page says state Medicaid agencies can join the model beginning in May 2026 through January 1, 2027, and that coverage for weight loss under BALANCE will launch in Medicaid "as early as May 2026" [2].
What BALANCE is
BALANCE stands for Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth. It is a voluntary model in which CMS negotiates drug prices and coverage terms directly with GLP-1 manufacturers on behalf of state Medicaid agencies and Medicare Part D plan sponsors [2]. Participation is voluntary for manufacturers, states and Part D plans [2].
To qualify, a product must be, or act as, a GIP, GLP-1 or glucagon receptor agonist (or a combination), and must have clinical evidence that at an FDA-approved dose it reduces body weight by at least 9.5% on average in a randomized trial [2]. CMS's drug list for the model includes all formulations of Mounjaro, Ozempic, Rybelsus and Wegovy, the KwikPen formulation of Zepbound, and Foundayo (orforglipron) — covering both currently approved indications such as type 2 diabetes and weight management [2]. Note that CMS lists only the KwikPen version of Zepbound, while Lilly's statement refers to Zepbound generally [1][2].
CMS also says all Medicaid beneficiaries getting GLP-1s for weight management under BALANCE will get access to a manufacturer-funded lifestyle support program at no cost, available during and after treatment [2]. CMS warns that patients would be subject to qualification rules set in the negotiations, including certain prior authorization requirements, so "this model will not guarantee coverage for any individual" [2].
The sources disagree on the Medicare timeline
Lilly's March 9 statement describes BALANCE reaching Medicare Part D on January 1, 2027, and describes the separate Medicare GLP-1 Bridge — which caps cost at no more than $50 per month with no deductible for drugs including Zepbound and orforglipron, if approved — as running July 1, 2026 through December 31, 2026 [1].
CMS's BALANCE page, last modified August 14, 2026, tells a different story. It states the Bridge has been extended through December 31, 2027, and answers a question about "the BALANCE Model not launching in Medicare in 2027" by saying the extension gives CMS more time to collect GLP-1 utilization data "ahead of potential implementation of BALANCE in Part D" [2]. In other words, the later CMS page indicates the Part D launch Lilly announced did not proceed as described.
Why it matters for patients
Medicare and Medicaid generally do not cover GLP-1s for the weight-loss indication, which is the gap BALANCE is meant to address [2]. For people with Medicare Part D, the practical near-term path in these documents is the Bridge, not BALANCE: CMS says eligible Part D beneficiaries are expected to have access through the Bridge starting July 2026, now running through December 31, 2027 [2].
The $50 and $245 figures in Lilly's statement apply to plans that choose to participate, and Lilly itself notes some basic Part D plans would differ [1]. Because participation is voluntary for plans and states, coverage will likely vary by where someone lives and which plan they have [2]. Whether and when BALANCE terms apply in Part D is not settled in these sources.
What happens next
Sources
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