CMS issued requests for applications from Medicare Part D plans and state Medicaid agencies to join the voluntary “Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth,” known as BALANCE, model.
Under the model, CMS will negotiate with manufacturers on pricing for GLP-1 medications used for weight management and metabolic conditions, acting on behalf of state Medicaid programs and Medicare Part D sponsors. The model builds off the White House’s most-favored-nation pricing agreements with Eli Lilly and Novo Nordisk for drugs that treat obesity, diabetes and related conditions. In December, CMS published a request for applications directed to manufacturers, as well.
The participating payers must cover all model drugs from the included manufacturers, and the Part D weight-loss coverage exclusion would not apply. The drugs must fall under a plan’s basic benefit structure.
Part D parent organizations would need to include at least 90% of their eligible population, preventing them from selectively testing the model with a few subsidiary plans. In order for the model to progress, CMS said they need at least 80% of Part D enrollment represented in the model. CMS is offering narrower risk corridor options for many participants, too.
The requests for applications also laid out specific cost-sharing limits for Part D plans: Enhanced alternatives and employer group waiver plans must cap beneficiary spending at $50 per month supply during the initial coverage phase. For basic alternative and actuarially equivalent plans, the cap is $125 per month supply.
Prior authorization would also be standardized across the model. The documents outline body mass index thresholds, provider attestation and confirmation that patients are pursuing lifestyle modification.
The model is slated to begin in 2026 for Medicaid and 2027 for Medicare Part D.
