A March analysis from KFF aims to shed light on CMS’ upcoming BALANCE model for GLP-1 coverage — highlighting financial requirements, operational mandates and unresolved policy questions — ahead of its 2027 launch.
The model, announced in December, builds on the White House’s most-favored-nation pricing deals with Eli Lilly and Novo Nordisk, and aims to expand obesity treatment access in Medicare and Medicaid.
Here are six takeaways from KFF’s report:
- Dual pricing requirements: Under the model, participating drug manufacturers must adopt supplemental rebate agreements with state Medicaid programs and most-favored-nation pricing
- Value-based arrangements: Participating manufacturers will provide lifestyle support programs and, as part of their agreements with CMS, must demonstrate how those programs meet requirements.
- Unresolved regulatory issues: CMS has not clarified how participating Medicare plans will comply with anti-discrimination requirements, especially around weight-based eligibility criteria.
- Uncertainty around adherence: Long-term outcomes such as patients’ medication adherence, side effects and sustained weight loss remain unaddressed, KFF said, raising concerns about the model’s real-world impact and cost-effectiveness.
- Implementation complexity: Stakeholders must navigate parallel requirements across Medicaid and Medicare, with few details yet on how CMS will standardize oversight or measure success.
- Pending guidance: Several program elements, including operational infrastructure and reporting expectations, are still undefined.
CMS has not released additional implementation guidance since announcing the BALANCE model in December, and more clarity is needed before stakeholders can fully assess feasibility and impact, the report said.
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