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The Centers for Medicare & Medicaid Services has announced a voluntary test of a model to give Medicare Part D plans and state Medicaid agencies the ability to cover GLP-1 medications used for weight management and metabolic health improvement.
The Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) Model builds on emerging evidence that combining access to GLP-1 medications with access to evidence-based lifestyle achieves better long-term health outcomes, CMS said.
“The model represents a major step toward potential expanded access and affordability for millions of Americans,” CMS said.
Participation is voluntary for manufacturers, states and plans. Additional information is expected early this year.
The BALANCE Model will launch in Medicaid as early as May and in Medicare Part D in January 2027.
CMS has issued a Request for Applications to manufacturers, which are due by Jan. 8. CMS has issued notices of intent for state Medicaid agencies and Medicare Part D plans, which are also due Jan. 8.
WHY THIS MATTERS
The model expands the government’s ability to negotiate directly with pharmaceutical manufacturers for lower net prices and standardized coverage terms.
Beneficiaries are expected to potentially get out-of-pocket limits.
The CMS Innovation Center will evaluate the model’s impact on costs, adherence, outcomes and beneficiary experience to determine whether it improves health and generates savings.
THE LARGER TREND
CMS made the announcement around the same time that the Food and Drug Administration approved Novo Nordisk’s once-daily Wegovy pill, the first oral GLP-1 medicine for obesity in the United States. The price for a 1.5-mg starter dose is $149 per month with savings offers, the company said.
Currently, GLP-1 medications are available only as an injectable.
The full launch of the pill is expected this month. It will be available in pharmacies and select telehealth providers.
Additional information on coverage and savings options for eligible patients, including other programs designed to help reduce out-of-pocket costs, will also be available at that time, Novo Nordisk said.
ON THE RECORD
“Today’s announcement builds upon our historic Most Favored Nations drug pricing deals’ goal of democratizing access to weight-loss medication, which has been out of reach for so many in need,” said CMS Administrator Dr. Mehmet Oz. “These actions further the administration’s bold plan to reform our country’s health systems and Make America Healthy Again.”
“The BALANCE Model will empower more Americans to live healthier lives by expanding access to GLP-1s that have shown to be a powerful tool against the development of diseases, such as diabetes, cardiovascular disease, and other metabolic conditions, which can negatively affect a person’s long-term health,” CMS Innovation Center Director Abe Sutton said. “Through this model, CMS will make GLP-1s more accessible for people with Medicare and Medicaid.”
Email the writer: SMorse@himss.org