CMS says BALANCE will not launch in Medicare Part D for 2027
CMS will not run the BALANCE Model in Medicare Part D in 2027 after a plan participation threshold went unmet, and instead extended the $50-a-month Medicare GLP-1 Bridge through December 31, 2027.
CMS told Medicare Part D plan sponsors on April 21, 2026 that the BALANCE Model will not launch in Part D for 2027 — one day after the deadline for plans to apply [1][4]. To avoid a gap in Medicare coverage of obesity drugs, the agency extended a separate short-term program, the Medicare GLP-1 Bridge, through December 31, 2027, instead of ending it on December 31, 2026 as originally planned [1][4]. The Medicaid side of BALANCE is unaffected and is still rolling out state by state [4].
What the threshold was
BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) is a voluntary CMS Innovation Center model that was scheduled to run in Part D from January 1, 2027 through December 31, 2031 [2]. Its launch was conditioned on what CMS called a "critical mass" of Part D plan participation, spelled out in Section 2.3.1 of the March 2026 request for applications [2][4]. Sources describe the bar slightly differently: Advisory Board reported it as "at least 80% of Part D sponsors" choosing to participate, while other accounts describe it as sponsors covering at least 80% of Part D enrollment [3][4]. Applications from plans were due April 20, 2026, and CMS had set a target of April 30, 2026 to tell plans whether it would proceed [2][3].
One trade guide reported that UnitedHealthcare publicly said it was "still working through" whether to participate and that Bloomberg reporting indicated CVS Health (Aetna) declined, leaving the math short [4]. That account also says the CMS memo framed the delay as "pending further evaluation and data collection," not a cancellation, and points to the CY2028 Advance Notice — typically released in January or February 2027 — as the next signal [4]. KFF, updating its brief on May 11, 2026, describes the move as an "indefinite delay" rather than a set restart date [1]. In other words, whether Part D BALANCE returns in 2028 is not yet known.
The market signals before the deadline were mixed. An Optum Advisory executive said most Part D sponsors did not believe the 80% threshold would be met, but many opted in anyway so they would not be left out if it did [3]. Under the negotiated terms, Eli Lilly and Novo Nordisk had both agreed to participate at a $245 net price per 30-day supply for all model drugs in 2027 [3].
Why it matters for patients
For people on Medicare who want a GLP-1 for weight management, the practical effect is that the Bridge is now the only federal pathway for 2027 — and it lasts a year longer than planned [1][4]. The Bridge runs July 1, 2026 through December 31, 2027, is nationwide, and sits outside Part D, so plans do not have to opt in and do not bear the cost risk for their enrollees [1]. Cost-sharing is $50 per month, and the covered drugs are all formulations of Foundayo (orforglipron) and Wegovy (semaglutide) plus the KwikPen formulation of Zepbound (tirzepatide) [1][4].
BALANCE would have offered a broader drug list and different cost-sharing tiers — $50 a month for enhanced plans or $125 for basic plans — so that wider menu is off the table for 2027 [3]. A prior authorization is still required for the Bridge, with a provider attesting that the prescription is for weight reduction and maintenance and that the person meets one of three BMI-based categories: BMI 35 or higher; BMI 30 or higher with heart failure with preserved ejection fraction, uncontrolled hypertension, or chronic kidney disease stage 3a or above; or BMI 27 or higher with prediabetes, prior heart attack, prior stroke, or symptomatic peripheral artery disease [1]. Medicare still cannot cover weight-loss drugs under regular Part D by law [1].
What happens next
State Medicaid agencies have until July 31, 2026 to apply for BALANCE, with start dates between May 1, 2026 and January 1, 2027 and an end date of December 31, 2031 [1][4]. As of January 2026, only 13 states covered GLP-1s for obesity in Medicaid, down from 16 in 2025 [1]. Separately, the negotiated Medicare price for semaglutide takes effect in 2027 [1].
Images from the sources
Sources
- https://www.kff.org/medicare/what-to-know-about-the-balance-model-for-glp-1s-in-medicare-and-medicaid
- https://www.cms.gov/priorities/innovation/files/balance-part-d-plans-rfa.pdf
- https://www.advisory.com/daily-briefing/2026/04/15/balance-model-oi-ec
- https://therxindex.com/guides/cms-balance-model-glp-1-coverage-criteria/
- https://www.kff.org/medicare/what-to-know-about-the-balance-model-for-glp-1s-in-medicare-and-medicaid/
Semaglutides.org is for information only and is not medical advice. Always talk to a licensed healthcare provider about your own care. Some links to telehealth services are affiliate links, labeled where they appear.