Only Indiana has committed to the BALANCE Medicaid pricing model while 29 states have declined

Nine months after the Centers for Medicare and Medicaid Services rolled out the BALANCE model, which lets state Medicaid programs buy GLP-1 drugs at federally negotiated prices, only Indiana has committed to take part, and 29 state Medicaid programs have declined, according to a report from the Public Sector Healthcare Roundtable ^[1]. States that said no pointed to cost, tight budgets and doubts about whether the model would stay affordable over time ^[1].

CMS's own webpage for the model still lists the number of participants as "not applicable" ^[2]. That is the practical gap: the federal government negotiated discounted prices for weight-loss drugs, opened the door to states in the spring and set a closing date, but its public page does not yet name a single participating state ^[2].

What the model actually does

BALANCE is run by CMS and allows the agency to negotiate drug prices with manufacturers on behalf of state Medicaid programs and Medicare Part D plans ^[2]. The key design feature is that participation is voluntary at every level, for manufacturers, for states and for plans ^[2]. Nothing in the model requires a state to cover GLP-1 medications for obesity, and nothing requires a drugmaker to offer a price a state finds workable.

That voluntary structure is why the announcement of negotiated prices and actual coverage for patients are two different things. A state that declines keeps whatever Medicaid drug coverage rules it already has. Medicaid programs differ widely in whether they pay for GLP-1s when the reason is obesity rather than type 2 diabetes, and the sources here do not lay out state-by-state coverage rules.

Several important details are not available in the sources. The Roundtable report, as summarized, does not name which 29 states declined, and it does not account for the remaining states and territories that have neither committed nor formally said no ^[1]. The specific prices CMS negotiated, which manufacturers agreed to participate, which products are included and when Indiana's participation would begin are also not spelled out in the available material ^[1][2]. The exact closing date CMS set for states to sign up is referenced but not stated ^[2].

Why it matters for patients

For people on Medicaid who have been waiting to learn whether their state will pay for a GLP-1 for obesity, this is the concrete consequence: in 29 states, the answer for now is that the federal discount route is not being used ^[1]. Coverage in those states continues to depend on existing state rules, prior authorization requirements and formularies, none of which change because CMS negotiated a price.

The reasons states gave matter too. Cost concerns and questions about long-term financial sustainability suggest that even a discounted price can strain a Medicaid budget when the eligible population is large ^[1]. Obesity affects a substantial share of Medicaid enrollees, and a lower per-prescription price still multiplies quickly across a state's rolls. That tension helps explain why a program billed as a cost-cutting tool has drawn one taker so far.

For people with commercial insurance or Medicare, BALANCE does not directly change what they pay, although the model does extend to Medicare Part D plans that choose to join ^[2]. Whether any Part D plans have signed up is not reported in these sources.

What happens next

The most useful signal to watch is CMS's model page, which will presumably shift off "not applicable" if and when participants are formally listed ^[2]. Indiana's commitment has not yet translated into published details about start dates, covered drugs or enrollee eligibility, at least not in the material available here ^[1].

It is also not yet known whether CMS will change the model's terms, extend the sign-up window or add incentives to draw more states in. Until that happens, a Medicaid enrollee's access to semaglutide (Ozempic, Wegovy, Rybelsus) or tirzepatide (Mounjaro, Zepbound) will keep coming down to their own state's rules rather than the federal negotiation.