The U.S. Centers for Medicare and Medicaid Services (CMS) has announced a landmark voluntary program to expand coverage for popular GLP-1 weight-loss drugs. This initiative follows a recent price-cut agreement between the Trump administration and pharmaceutical leaders Eli Lilly and Novo Nordisk.
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Under the new BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive Health) initiative, CMS aims to drastically lower the cost barrier for obesity treatments:
- Medicare Out-of-Pocket Cap: Eligible beneficiaries will pay $50 for a 30-day supply of injectables like Wegovy and Zepbound.
- Government Pricing: The government will pay $245/month for injectables and $149/month for upcoming weight-loss pills.
- Cash Payers: The $149/month price for pills will also be extended to patients paying out-of-pocket.
Rollout Timeline
CMS is implementing a phased approach to ensure access as quickly as possible:
- July 2026: A Medicare “Bridge” demonstration begins, offering negotiated prices early.
- May 2026: Earliest possible launch for state Medicaid programs.
- January 2027: Full Medicare Part D integration for the BALANCE model.
Program Requirements
The program isn’t just about medication; it focuses on “comprehensive health” by bundling drugs with lifestyle support:
- Holistic Care: CMS will bundle medications with evidence-based nutrition and lifestyle counseling.
- Voluntary Participation: The model is optional for drug manufacturers, states, and private insurance plans.
- New Approvals: The announcement follows Monday’s FDA approval of Novo Nordisk’s weight-loss pill, while Lilly’s oral version remains under review.
“This program aims to increase access to select GLP-1 medications and support for healthy lifestyle choices.” — Mehmet Oz, CMS Administrator
Editing by Suresh Jajam
