Lilly says some basic Medicare drug plans may charge more than $50 for its GLP-1 medicines

Eli Lilly said on March 9 that a small number of basic Medicare Part D drug plans may not hold patients' out-of-pocket costs to the $50 monthly cap that has been promoted for its GLP-1 medicines, as federal officials released new details about how the coverage program will work ^[1][2].

The Centers for Medicare and Medicaid Services issued implementation details for the Medicare and Medicaid CMMI BALANCE Model that day ^[1]. Under the model, CMS sets standardized coverage terms by directly negotiating guaranteed net prices, potentially capping out-of-pocket costs and bundling evidence-based lifestyle support ^[2]. The agency said it has completed negotiations with Lilly and Novo Nordisk for the new weight-loss drug coverage model ^[2], and state Medicaid agencies and Medicare Part D plan sponsors can now apply to participate ^[2].

The terms for Lilly's medicines are specific. Beginning January 1, 2027, Zepbound (tirzepatide), Mounjaro (tirzepatide) and orforglipron, if approved, will be available through Medicare Part D participating plans, with most beneficiaries facing out-of-pocket costs capped at $50 per month after the deductible is met ^[1]. Before patients reach their deductible, cost sharing will be limited to $245 per month plus a dispensing fee ^[1]. State Medicaid programs can apply to participate beginning May 1, 2026, with a rolling start ^[1].

Lilly said the majority of Medicare plan options will honor the $50 out-of-pocket cap, but that cost sharing will vary for beneficiaries in a small number of basic Medicare Part D plans ^[1][2]. CMS said last year that eligible Medicare beneficiaries would pay $50 for a month's supply of GLP-1 drugs, including Lilly's injectable Mounjaro and Zepbound ^[2].

A separate but related program, the Medicare GLP-1 Bridge Model, runs from July 1, 2026 through December 31, 2026. It lets Medicare Part D beneficiaries get medications including Zepbound and orforglipron, if approved, at no more than $50 per month with no deductible ^[1].

Why it matters for patients

Medicare Part D is the prescription drug benefit that helps Medicare enrollees pay for outpatient medications through approved private plans ^[2]. That structure is why the $50 figure is not guaranteed for everyone: what a beneficiary actually pays depends on which plan they are enrolled in and on how that plan is designed, and Lilly has said only a small number of basic plans may set cost sharing above the cap ^[1][2].

Timing matters too. Under the BALANCE model, the $50 cap applies after the deductible is met, and costs before that point are limited to $245 per month plus a dispensing fee ^[1]. The Bridge model, which begins July 1, 2026, has no deductible ^[1].

Lilly said it will actively educate patients and their physicians about plan options and about "smoothing programs" that can help patients get medications at the lowest possible out-of-pocket costs ^[1][2]. Which specific plans will exceed the cap, how many beneficiaries would be affected, and how much more they might pay have not been disclosed.

What happens next

• May 1, 2026: state Medicaid programs can apply to participate in the BALANCE model, with a rolling start ^[1].
• July 1, 2026: the Medicare GLP-1 Bridge Model begins and runs through December 31, 2026 ^[1].
• January 1, 2027: Zepbound, Mounjaro and orforglipron, if approved, become available through Medicare Part D participating plans under the BALANCE model ^[1][2].