Background

On April 21, the Centers for Medicare & Medicaid Services (CMS) announced that it would delay the implementation of the Medicare Part D portion of Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) Model and extend the Medicare GLP-1 Bridge demonstration through December 31, 2027. CMS indicated that the delay would provide additional time to evaluate the model and collect data, but did not offer a new implementation timeline.

Initially announced in December 2025, BALANCE was designed as a voluntary demonstration program that would expand access to GLP-1 medications for weight loss to Medicare and Medicaid beneficiaries. The Part D component of BALANCE would have provided eligible beneficiaries in participating plans with expanded access to GLP-1s beginning in the 2027 plan year. To fill the gap in GLP-1 access ahead of BALANCE’s implementation, CMS announced a short-term GLP-1 Bridge payment demonstration running from July through December 2026. With the delay of Part D BALANCE, the GLP-1 Bridge has been extended through December 31, 2027.

GLP-1 Bridge Design

Under statute, drugs used for weight loss are excluded from Part D coverage; GLP-1s can be covered when prescribed for other eligible Part D indications such as type 2 diabetes or cardiovascular disease. Beginning in July 2026, the GLP-1 Bridge will provide Part D beneficiaries that meet certain body mass index criteria access to GLP-1s for weight management. Beneficiaries will pay a $50 copay for GLP-1s under the demonstration and participating manufacturers will provide eligible drugs at a net price of $245 per monthly supply.

The GLP-1 Bridge demonstration will operate outside of the Part D benefit, meaning the $50 copay paid by beneficiaries will not count toward the deductible or out-of-pocket (OOP) cap, nor will plan sponsors bear liability for these drugs. Beneficiaries using GLP-1s for other indications coverable under the Part D benefit will continue to access these drugs through their Part D plan.

While the GLP-1 Bridge provides a temporary pathway for GLP-1 access outside of the Part D benefit, BALANCE was designed as a voluntary demonstration that would integrate GLP-1 coverage directly into the Part D benefit, meaning that plans would bear financial responsibility for participating GLP-1 costs, and beneficiary copays would count toward the deductible and OOP cap.

BALANCE Model Challenges

While CMS did not provide details on its reasons for delaying BALANCE, the model’s impact on plan bids and uncertainty regarding beneficiary utilization of GLP-1s, as well as the risk of adverse selection, may have factored into the delay.

BALANCE was announced less than six months before 2027 plan bids are due to CMS on June 1, 2026.while Plan bids use historic drug utilization and cost data to estimate future drug spending. Because GLP-1s for weight loss have never been covered under Part D, there is no existing claims data to reliably estimate how many Medicare beneficiaries may qualify under the model and its impact on uptake and utilization of GLP-1s. Without this data to anchor projections, plan sponsors faced considerable uncertainty in accurately estimating their expected drug spend, pricing competitive bids, and setting appropriate beneficiary premiums with expanded GLP-1 coverage. CMS noted that the extension of GLP-1 Bridge would provide plans with additional data to transition to potential BALANCE implementation in the future.

A related concern is the risk of adverse selection among participating plans. Plans that opted into BALANCE may have faced a higher-than-average concentration of beneficiaries taking GLP-1s for weight loss, which could have resulted in higher plan costs.  To address the risk of adverse selection and limit financial burden associated with higher-than-average GLP-1 utilization, CMS established a minimum participation threshold in order to proceed with BALANCE (i.e., at least 80% of Part D beneficiaries were enrolled in a participating plan) and provided narrowed risk corridors in select circumstances. Even with these risk mitigation strategies in place, BALANCE may not have provided sufficient incentives for broad voluntary plan participation.

These uncertainties represent fundamental challenges in introducing a high-cost, high-demand drug benefit into the Part D program with limited data and significant financial uncertainty.

Considerations for the Future of GLP-1 Coverage in Part D

The extension of the GLP-1 Bridge raises several near-term considerations and is likely to shape the future of GLP-1 access in Part D. As CMS implements the GLP-1 Bridge, additional support and education may be needed for providers, pharmacies, and beneficiaries to reduce confusion and potential access delays when determining whether a GLP-1 is covered under a plan’s Part D benefit vs. the GLP-1 Bridge demonstration. Additionally, the extension of the GLP-1 Bridge demonstration carries important financial implications for beneficiaries, as it operates outside of the Part D benefit, and coincides with substantial increases in both deductible and OOP cap in 2027. While total beneficiary OOP costs will be higher than they would have been under BALANCE, coverage under the GLP-1 Bridge will apply to all Part D beneficiaries.

The delay of the BALANCE Model also creates opportunities for stakeholders to engage with CMS on model design, particularly as new data on uptake and utilization emerge from Bridge. Stakeholders should consider what changes in model parameters and plan incentives may be needed to encourage future participation, how pipeline products may be incorporated, and how beneficiary utilization patterns may change if copays are counted toward OOP accumulation. Implications of a future model incorporating GLP-1s into the Part D benefit will vary by plan type (e.g., Medicare Advantage drug plans vs. standalone Prescription Drug Plans) and will be influenced by other policy interactions such as Medicare Drug Price negotiation and Most-Favored Nation pricing.

Beyond GLP-1s, the Bridge demonstration may inform new approaches for CMS-led benefit administration in Part D, including how access for similar high-cost and high-demand drugs could be managed in the future.

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