Impacted: Medicaid, Medicare Part D clients

What you need to know

The Centers for Medicare and Medicaid Services (CMS) has introduced the voluntary Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) Model to expand access to glucagon-like peptide-1 (GLP-1) drugs for weight management and metabolic health, pairing drug access with evidence-based lifestyle and nutrition support. 

States and Medicare Part D sponsors interested in participating in this model should complete a notice of intent (NOI) by Jan. 8, 2026. NOIs are non-binding for Part D sponsors and plan sponsors who submit their NOI will receive participation updates from CMS.

Prime Therapeutics (Prime) encourages clients to review the BALANCE Model, consider participation and submit an NOI by Jan. 8, 2026.

Overview

BALANCE is designed to broaden access to comprehensive weight management care by combining GLP-1 drugs with lifestyle interventions to improve metabolic health. Under BALANCE, CMS will negotiate pricing and coverage terms directly with participating manufacturers on behalf of state Medicaid agencies and Part D sponsors to establish guaranteed net pricing. Participation could begin as early as May 2026 for Medicaid, with Part D beginning in January 2027.

All states and territories that participate in the Medicaid Drug Rebate Program (MDRP) will be eligible to participate in the model. The model will launch with a rolling start in May 2026, allowing states to opt in between May 2026 and January 2027 to support operational flexibility. Participating states will adopt CMS-negotiated key terms for beneficiaries in both fee-for-service Medicaid and Medicaid managed care. 

CMS will publish participation models and operating guidance in early 2026, including covered products, clinical criteria and any beneficiary cost-sharing parameters agreed through negotiations. 

Medicare Part D bridge

To enable earlier access for Part D, CMS is expected to launch a “bridge program” starting in July 2026. The bridge is expected to operate as a short-term pathway for beneficiaries to access GLP-1s ahead of BALANCE’s full Part D start in 2027. It will operate outside of the traditional Part D benefit, and plans will not be responsible for costs. Eligible beneficiaries will pay $50 per month for GLP-1 drugs. CMS has indicated it plans to share additional information in early 2026. 

Next steps and additional information

Prime encourages clients to review this new model, participation requirements and preparing operations for both the bridge and full BALANCE launch. Additional information, including model details and FAQs can be accessed here.

• States and Part D sponsors interested in participating in this model should submit their NOI by Jan. 8, 2026.
• Prime encourages clients to submit the NOI in advance of the deadline if awaiting participation models and operating guidance to aid their decision to opt in. 

Questions

Reach out to your Prime account team representative.