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BALANCE GLP-1 model opens to state Medicaid programs, applications due July 31

States that join would adopt CMS-negotiated prices and coverage rules for Mounjaro, Ozempic, Wegovy and other GLP-1s, but coverage for obesity is not guaranteed [1][2][3].

By the Semaglutides news desk·

State Medicaid agencies can begin joining the BALANCE model on May 1, 2026, with participation phased in on a rolling basis through January 1, 2027 [1][2][3]. States that want in must apply by July 31, 2026 and execute a State Agreement with CMS by January 1, 2027 [2][3]. The model is scheduled to run through December 2031 [3].

BALANCE — short for Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth — is a voluntary CMS Innovation Center model. Under it, CMS negotiates drug prices and coverage terms directly with GLP-1 manufacturers on behalf of state Medicaid agencies rather than leaving each state to bargain alone [1][2]. Participating states then adopt those standardized terms through a supplemental rebate agreement with each participating manufacturer [2]. Participation is voluntary for manufacturers, states and Part D plans [1][2].

The model covers all formulations of Mounjaro, Ozempic, Rybelsus and Wegovy, the KwikPen formulation of Zepbound, and Foundayo, for both currently covered uses such as type 2 diabetes and for weight management [1]. Ozempic, Wegovy and Rybelsus contain semaglutide; Mounjaro and Zepbound contain tirzepatide [3].

Patients receiving a model drug for weight management in Medicaid would qualify under standardized criteria that match those used in the Medicare Bridge program: a BMI of 35 or higher, or a BMI of 30 or higher along with heart failure with preserved ejection fraction, uncontrolled hypertension, or chronic kidney disease stage 3a or above, or a BMI of 27 or higher with prediabetes, a prior heart attack, a prior stroke, or symptomatic peripheral artery disease [3]. The Medicaid model also lists type 2 diabetes, noncirrhotic MASH and obstructive sleep apnea as qualifying diagnoses [3]. Beneficiaries getting a model drug for weight management must be 18 or older [3].

Everyone who receives a model drug for weight management in Medicaid also gets access to a lifestyle support program paid for by the manufacturer at no cost to the patient, available during and after treatment [1][2].

CMS says the model does not guarantee coverage for any individual. Patients would still be subject to qualifications set in the negotiations between CMS and manufacturers, including certain prior authorization requirements [1]. It has not been reported which states have applied or which manufacturers have signed participation agreements.

The Medicare side is moving differently. CMS announced on April 21, 2026 that BALANCE in Medicare Part D is indefinitely delayed, and extended the separate Medicare GLP-1 Bridge through December 31, 2027 [3]. The Bridge opened July 1, 2026 and gives eligible Part D beneficiaries access to all formulations of Foundayo and Wegovy and the KwikPen formulation of Zepbound for a flat $50 monthly copay [1][3][4].

Why it matters for patients

Federal law makes covering weight-loss drugs optional for state Medicaid programs, so where a person lives largely determines whether a GLP-1 is covered for obesity [3]. As of January 2026, 13 states covered these drugs for that purpose, down from 16 in 2025 [3]. BALANCE is designed to let more states offer coverage by lowering the negotiated price, but it only applies in states that choose to join, and CMS says individual coverage is not guaranteed [1].

GLP-1 use is already large in both programs. In 2024, Medicaid recorded 8.4 million GLP-1 prescriptions and $8.6 billion in gross spending, while Medicare recorded 21.8 million claims and $27.5 billion in gross spending before rebates [3]. About half of GLP-1 users (56%) say the drugs were difficult to afford, including one in four who said they were "very difficult" to afford [3].

Because the model runs through state supplemental rebate agreements, the coverage terms, prior authorization rules and any cost sharing a patient faces would come from the CMS-negotiated key terms as adopted by that state, not from the ordinary Medicaid drug benefit [1][2].

What happens next

  • July 31, 2026: deadline for state Medicaid agencies to submit applications [2][3].
  • January 1, 2027: deadline for states to execute agreements with CMS; the rolling start dates for participating states run through this date [2][3].
  • December 31, 2027: the Medicare GLP-1 Bridge ends [1][3].
  • December 31, 2031: BALANCE ends for state Medicaid agencies [3].

CMS has said it may modify model terms or cancel the model, and that the terms described in the state application document may differ from the final agreements [2].

Sources

  1. https://www.cms.gov/priorities/innovation/innovation-models/balance
  2. https://www.cms.gov/priorities/innovation/files/balance-state-medicaid-rfa.pdf
  3. https://www.kff.org/medicare/what-to-know-about-the-balance-model-for-glp-1s-in-medicare-and-medicaid/
  4. https://health.usnews.com/medicare/articles/does-medicare-cover-ozempic
  5. https://www.aarp.org/medicare/glp1-weight-loss-copay-program/

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