Indiana alone in joining federal Medicaid GLP-1 pricing model as 29 states decline
One state has signed on to a federal program meant to lower GLP-1 drug prices for Medicaid, leaving enrollees in the 29 states that declined without that route to coverage.
Nine months after the Centers for Medicare and Medicaid Services opened the BALANCE model to states, Indiana is the only state that has committed to buy GLP-1 weight-loss drugs through it, while 29 state Medicaid programs have declined, according to the Public Sector Healthcare Roundtable [1].
The BALANCE Model allows CMS to negotiate drug prices with drugmakers on behalf of states and Medicare Part D plans [2]. Participation is voluntary for manufacturers, states and plans [2]. CMS opened the model to states in the spring and set a closing date, but the agency's own model page still lists the number of participants as "not applicable" [2].
The roundtable reported that the states that declined cited cost concerns, budget constraints and doubts about whether the model's finances can hold up over time [1]. Its finding came nine months after CMS introduced the model [1].
Which 29 states declined has not been made public. What Indiana agreed to pay, and when its participation would begin, has not been reported [1]. Whether any other state is still considering the program has not been reported.
For Medicaid enrollees, the gap between the federal announcement and actual state sign-ups is the practical part of the story. Enrollees have been waiting to hear whether their state will cover a GLP-1 for obesity [2]. Because the model is voluntary at every level — drugmakers, states and plans — a state can pass on it even if manufacturers agree to negotiated prices [2].
Why it matters for patients
People covered by Medicaid in the 29 states that declined will not get lower GLP-1 prices through BALANCE in the near term [1]. The model was designed to let states buy the drugs at prices negotiated by CMS rather than at whatever each state could negotiate alone [2].
That leaves coverage for obesity treatment in those states where it was before the model was launched. Indiana's decision, by contrast, means its Medicaid program has committed to the model, though the terms have not been reported [1].
Whether a GLP-1 is covered for weight loss still depends on the state a patient lives in. The federal page for the model lists no participating states, so there is no federal list showing which Medicaid programs have signed on [2].
What happens next
CMS has set a closing date for states to join the model, but that date has not been reported [2]. The model page continues to list the number of participants as "not applicable" [2], and no state besides Indiana has been announced [1].
No start date for Indiana's participation, no list of which GLP-1 products the model covers, and no timeline for additional states have been disclosed [1].
Sources
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