Lilly warns that some Medicare plans may charge more than the promised $50

Eli Lilly said on March 9, 2026, that while most Medicare Part D plans will honor a promised $50-per-month price for its GLP-1 medicines, some basic plans may charge patients more, depending on how each plan is structured ^[1][2]. The statement came the same day the Centers for Medicare and Medicaid Services (CMS) released new details on the CMMI BALANCE Model, a program meant to expand access to GLP-1 drugs and lower what patients pay out of pocket ^[1].

Under the BALANCE Model, Lilly's Zepbound (tirzepatide), Mounjaro (tirzepatide), and orforglipron — if the Food and Drug Administration approves it — will be available through Medicare Part D plans starting January 1, 2027 ^[1]. Lilly said most beneficiaries will have their out-of-pocket costs capped at $50 a month once they meet their deductible, and at $245 a month plus a dispensing fee before they meet it ^[1]. State Medicaid programs can apply to join the program on a rolling basis starting May 1, 2026 ^[1].

But Lilly's own statement included a caveat: "cost sharing will vary for beneficiaries in a small number of basic Medicare Part D plans" that may not honor the $50 cap ^[1][2]. Reuters reported the same day that CMS said it had completed price negotiations with Lilly and Novo Nordisk, and that state Medicaid agencies and Part D plan sponsors could now apply to join the model, which sets standardized coverage terms through negotiated guaranteed net prices and may bundle in lifestyle support programs ^[2]. CMS had said last year that eligible Medicare beneficiaries would pay $50 for a month's supply of drugs like Mounjaro and Zepbound, without qualifying that pledge with plan-level exceptions ^[2].

Lilly said it will work to educate patients and physicians about plan options and about "smoothing programs" designed to help people find the lowest possible out-of-pocket cost ^[1]. The company also pointed to a separate, shorter-term program, the Medicare GLP-1 Bridge Model, which lets Part D beneficiaries access Zepbound and orforglipron (if approved) for no more than $50 a month with no deductible, running from July 1, 2026, through December 31, 2026 ^[1].

Why it matters for patients

For Medicare beneficiaries taking or considering Zepbound, Mounjaro, or a future prescription for orforglipron, the headline $50 figure has been the number most widely reported. Lilly's own admission that some basic plans may not follow that cap means the price a patient actually pays could depend heavily on which specific Part D plan they are enrolled in, not just on whether they qualify for the broader program ^[1][2]. The sources do not specify how many plans fall into this smaller group, how much higher those costs could run, or which insurers are affected, so patients in Part D plans will not know their exact cost until plan-level details are published.

The timing gap also matters. The Medicare GLP-1 Bridge Model, with its no-deductible $50 cap, is scheduled to run only from July through December 2026, while the longer-term BALANCE Model with the same headline price does not start until January 1, 2027 ^[1]. What happens to pricing in the gap between those two programs, or for patients not covered by either, is not addressed in the available sources.

What happens next

State Medicaid programs can begin applying to join the BALANCE Model on May 1, 2026, on a rolling basis ^[1]. The Medicare GLP-1 Bridge Model takes effect July 1, 2026, and runs through the end of that year ^[1]. The CMMI BALANCE Model itself begins January 1, 2027, when Zepbound, Mounjaro, and orforglipron (pending FDA approval) become available through participating Part D plans ^[1]. Lilly said it will continue working with CMS, health plans, providers, and pharmacists to try to extend the $50 access to more Medicare patients ^[1].