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BALANCE opens to state Medicaid programs on a rolling basis

CMS began letting state Medicaid programs join the BALANCE model on May 1, 2026, with standardized coverage rules and negotiated rebates for GLP-1 drugs including Mounjaro, Ozempic, Wegovy and the Zepbound KwikPen.

By the Semaglutides news desk·

Starting May 1, 2026, state Medicaid agencies could begin joining the federal BALANCE model, a voluntary program in which CMS negotiates GLP-1 prices and coverage terms directly with drugmakers on behalf of states [1][2]. States had until July 31, 2026 to apply and had to sign a State Agreement with CMS by January 1, 2027, so participating states come online on a rolling basis rather than all at once [2][3].

BALANCE stands for Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth. It was created under section 1115A of the Social Security Act, the CMS Innovation Center's model-testing authority, and is scheduled to run through December 2031 [2][3].

What the model covers

CMS negotiated a single set of "Medicaid Key Terms" with each participating manufacturer during a pre-implementation period that ran January 12 through February 5, 2026 [2]. States that join adopt those terms and then sign supplemental rebate agreements with each participating manufacturer [2]. In 2026 and 2027, participating states are required to adopt the key terms for all model drugs from all participating manufacturers [2].

According to CMS, the drugs in the model are all formulations of Mounjaro, Ozempic, Rybelsus and Wegovy, the KwikPen formulation of Zepbound, and Foundayo — covered both for indications already covered, such as type 2 diabetes, and for weight management [1]. Mounjaro and Zepbound are tirzepatide; Ozempic, Wegovy and Rybelsus are semaglutide; Foundayo is orforglipron. To qualify, a product must be a GIP, GLP-1 or glucagon receptor agonist (or a combination), be FDA-approved for weight management or expected to be by January 1, 2027, and have trial evidence of at least 9.5% average body weight reduction at an approved dose [1][2].

The coverage criteria are standardized. KFF's summary of CMS materials shows Medicaid BALANCE covers type 2 diabetes, noncirrhotic MASH, obstructive sleep apnea, a BMI of 35 or higher, a BMI of 30 or higher with conditions such as heart failure with preserved ejection fraction, uncontrolled hypertension or chronic kidney disease stage 3a or above, and a BMI of 27 or higher with pre-diabetes, prior heart attack, prior stroke or symptomatic peripheral artery disease [3]. Beneficiaries getting a model drug for the expanded weight-management indication must be 18 or older [3]. Everyone receiving a GLP-1 for weight management under Medicaid BALANCE is also offered a manufacturer-funded lifestyle support program at no cost [1].

Why it matters for patients

Federal law lets states decide whether Medicaid covers drugs used for weight loss, and coverage has been shrinking: only 13 states covered GLP-1s for obesity as of January 2026, down from 16 in 2025, amid state budget pressure and federal funding cuts [3]. BALANCE is the main federal vehicle that could reverse that, but it is voluntary for both states and manufacturers, and CMS says plainly that the model "will not guarantee coverage for any individual" [1].

Even where a state joins, access runs through the standardized criteria and prior authorization requirements negotiated between CMS and manufacturers [1]. That means a person's BMI, diagnoses and paperwork — not just a prescription — will determine whether a model drug is covered for weight management.

The stakes are large for state budgets too. Medicaid already recorded 8.4 million GLP-1 prescriptions and $8.6 billion in gross spending in 2024, before rebates [3].

The Medicare side has diverged. CMS announced on April 21, 2026 an indefinite delay of BALANCE in Part D, and instead extended the separate Medicare GLP-1 Bridge, which runs July 1, 2026 through December 31, 2027 and offers eligible Part D enrollees select weight-loss drugs for a flat $50 monthly copay [1][3][4].

What happens next

  • July 31, 2026: deadline for state Medicaid agencies to apply [2][3].
  • Through January 1, 2027: rolling start dates as states execute agreements with CMS [2][3].
  • December 31, 2027: Medicare GLP-1 Bridge ends [1][3].
  • December 31, 2031: BALANCE ends for state Medicaid agencies [2][3].

Which states actually signed on is not established by these sources. The CMS model page, last modified August 14, 2026, still lists the model's stage as "Announced" and the number of participants as "N/A" [1]. CMS also says it expects to renew negotiations as new products enter the market and prices change [1].

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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