GLP-1 BALANCE Model On Hold
The Trump administration’s effort to bring GLP-1 drugs for the obese to Medicare, BALANCE, is on hold. The Centers for Medicare and Medicaid Services (CMS) planned to negotiate lower GLP-1 prices for Medicaid and Medicare Part D coverage and have health plans and pharmacy benefits managers (PBMs) agree to offer the drugs in the programs. But too few applicants applied to participate, likely due to costs and risk. Critical mass in Part D, covering 80% of Part D enrollment, was not met. The Medicaid portion of the pilot will still move forward. In Medicare, to gather necessary data, CMS now plans on funding coverage through the end of 2027 before proceeding with the model.
At the same time, UnitedHealthcare said it was hoping to participate in both the BRIDGE program in 2026 and in BALANCE.
Additional articles: https://www.beckershospitalreview.com/glp-1s/cms-pauses-weight-loss-balance-model-indefinitely-for-medicare/ and https://www.beckerspayer.com/payer/medicare-advantage/unitedhealthcare-eyes-cms-balance-glp-1-model/
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https://www.modernhealthcare.com/politics-regulation/mh-medicare-glp-1-weight-loss-coverage
