Is expanded access to GLP-1 medicines hanging in the BALANCE as CMS delays its payment and coverage model?

According to reports, plans to expand access to GLP-1 medicines through CMS’s BALANCE Model have been delayed, with the Medicare Part D portion rollout now postponed pending further evaluation. In the interim, the temporary “Medicare GLP-1 Bridge” demonstration will be extended while additional data on GLP-1 utilization are collected.

The Centers for Medicare & Medicaid Services (CMS) BALANCE Model, designed to expand access to GLP-1 medicines across Medicare and Medicaid, appears to face uncertainty following reports of a delay to its implementation.

Announced through its Innovation Center (CMMI) at the end of 2025, CMS intended the Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) Model to increase access to select GLP-1 therapies alongside evidence-based lifestyle interventions. Under the voluntary model, CMS would negotiate pricing and coverage terms with manufacturers on behalf of state Medicaid agencies and Medicare Part D plan sponsors, with the aim of improving cardiometabolic outcomes while managing program spending.

However, recent communications suggest that the future of the model, particularly its Medicare Part D component, is now less certain. Medicare Part D, which provides outpatient prescription drug coverage through private plans for Medicare beneficiaries, was a central pathway for expanding access under BALANCE. According to reports, CMS has informed stakeholders via a Health Plan Management System (HPMS) communication that it will delay implementation of the Medicare Part D portion of the BALANCE Model for calendar year 2027, pending further evaluation and data collection. The agency said the approach would provide additional time and evidence to inform any future rollout of the model within Part D.

In parallel, CMS has confirmed that it will extend the Medicare GLP-1 Bridge, a temporary payment demonstration, until December 31, 2027. Originally introduced as a short-term measure ahead of BALANCE, Bridge allows eligible beneficiaries with access to certain GLP-1 medicines outside of the Medicare Part D benefit structure. The demonstration is scheduled to begin on July 1, 2026, with CMS working alongside plans, providers, pharmacies, and manufacturers to support its rollout.

In its memo, CMS indicated that feedback from Part D sponsors played a role in the decision, with plans suggesting that extending the Bridge would provide additional time and data to support a smoother transition to any future BALANCE implementation. The delay also comes amid reports that participation levels among major insurers may have been lower than anticipated. The structure of the BALANCE Model requires plan participation, with the program expected to proceed only if plans covering a substantial proportion of Medicare beneficiaries agreed to take part.

Whilst rollout of the BALANCE Model in Medicare Part D remains paused, the model will continue to move forward in Medicaid. CMS will accept applications from state Medicaid agencies through July 31, 2026, with participation beginning between May 2026 and January 2027, depending on state readiness. States that do not join by January 2027 may only participate at CMS discretion.