Deadline passes for Medicare Part D plans to join the BALANCE Model

Medicare Part D drug plan sponsors faced a deadline of April 20, 2026 to apply for participation in the BALANCE Model, a Center for Medicare and Medicaid Innovation program meant to let Medicare temporarily cover GLP-1 drugs for obesity, a use the program currently does not cover under federal law.^[1] One day later, on April 21, 2026, the Centers for Medicare & Medicaid Services (CMS) announced it was delaying the BALANCE Model in Part D indefinitely.^[1]

The BALANCE Model, short for Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth, was originally set to run in Medicare from January 2027 through December 2031.^[1] Drug manufacturers had until January 8, 2026 to apply, followed by a pre-implementation period from January 12 through February 5, 2026 to work out contract terms with CMS.^[1] Under the model as designed, eligible beneficiaries would have needed a body mass index of 35 or higher, or a BMI of 30 or higher plus certain conditions such as heart failure with preserved ejection fraction or chronic kidney disease, or a BMI of 27 or higher plus conditions like prediabetes or a prior heart attack, to qualify for coverage.^[1]

While the Medicare side of BALANCE has stalled, the Medicaid side has not. CMS says the Medicaid version of the model will launch on a rolling basis for states starting in May 2026, with state Medicaid agencies given until July 31, 2026 to apply, and the model running through December 31, 2031 for Medicaid.^[1] Currently only 13 states cover GLP-1s for obesity through Medicaid, down from 16 states in 2025, a drop that appears tied to the cost of coverage and state budget pressures.^[1]

Separately, CMS extended a different, already-running program called the Medicare GLP-1 Bridge, a short-term demonstration that gives Part D enrollees access to GLP-1s approved for weight loss at a $50 monthly copayment.^[1] That program, which covers all formulations of Foundayo and Wegovy along with the KwikPen formulation of Zepbound, was originally set to run from July through December 2026 but will now continue through the end of 2027.^[1] Unlike BALANCE, the Bridge program does not require Part D plans to opt in, and plans bear no financial risk for the costs.^[1]

Why it matters for patients

For now, the practical path to Medicare-covered weight-loss GLP-1s runs through the Bridge program, not BALANCE. Medicare beneficiaries who meet the BMI and clinical criteria can seek coverage through the Bridge starting July 1, 2026, with their provider submitting a prior authorization attesting to their qualifying diagnosis.^[1] That access is now guaranteed through the end of 2027 rather than ending in December 2026 as originally planned.^[1]

The delay of BALANCE in Part D means Medicare beneficiaries should not expect a broader, longer-term coverage model to take its place on the original 2027 timeline. Cost remains a central concern for many patients: KFF polling cited in the source found 56% of GLP-1 users said the drugs were difficult to afford, including one in four who called it "very difficult."^[1] Gross Medicare spending on GLP-1s reached $27.5 billion in 2024 across 21.8 million claims, while Medicaid gross spending hit $8.6 billion across 8.4 million prescriptions that year, underscoring why cost and budget concerns have shaped these program decisions.^[1]

Medicaid enrollees in the 13 states that cover obesity treatment are on a different, unaffected timeline, with the Medicaid BALANCE Model proceeding as planned through 2031.^[1]

What happens next

State Medicaid agencies have until July 31, 2026 to apply for the BALANCE Model, with rolling implementation continuing through January 1, 2027.^[1] The Medicare GLP-1 Bridge runs through December 31, 2027, giving Part D enrollees a defined window of $50 copay access to select obesity medications.^[1] Separately, a negotiated Medicare price for semaglutide, the molecule behind Ozempic, Wegovy, and Rybelsus, is set to take effect in 2027 following its selection for Medicare drug price negotiation in 2025.^[1] The sources reviewed do not specify why CMS chose to delay BALANCE in Part D rather than proceed, so the exact reasoning is not yet known from available reporting.