Understanding the BALANCE Model for GLP-1 Medications in Medicare and Medicaid
By
Meredith Freed
Juliette Cubanski
Elizabeth Williams
April 22, 2026
Clinical Scorecard: Understanding the BALANCE Model for GLP-1 Medications in Medicare and Medicaid
At a Glance
Category Detail
Condition Key Mechanisms Target Population Medicare and Medicaid beneficiaries with obesity, meeting specific clinical criteria. Care Setting
Key Highlights
Medicare prohibits coverage of obesity drugs, limiting access to GLP-1s for weight loss. CMS proposed the BALANCE Model to expand GLP-1 coverage for obesity starting January 2027, with the GLP-1 Bridge extended through 2027. The Medicare GLP-1 Bridge will provide temporary coverage for select GLP-1s for obesity from July to December 2026. Guideline-Based Recommendations
Diagnosis
Prior authorization required for GLP-1 prescriptions for weight reduction, based on specific clinical criteria. Management
Access to GLP-1 medications like Wegovy and Zepbound at a copayment of $50 per month for eligible beneficiaries, with clear eligibility criteria. Monitoring & Follow-up
Ongoing assessment of beneficiary eligibility based on BMI and clinical criteria, including specific metrics. Risks
Limited coverage may lead to high out-of-pocket costs for beneficiaries. Patient & Prescribing Data
Utilization of GLP-1s has increased significantly, with $27.5 billion in gross spending in Medicare, primarily for approved indications.
Clinical Best Practices
Ensure prior authorization requests are submitted for GLP-1 prescriptions. Monitor patient eligibility criteria for GLP-1 coverage. Educate patients on GLP-1s, including potential side effects and benefits. References
