As previously reported, NCPA has been actively advocating to CMS for fair payment for independent community and LTC pharmacies as they develop a model for Medicare and Medicaid coverage of weight loss drugs. That model, dubbed BALANCE, was formally announced by CMS on Dec. 23. Under the BALANCE Model, CMS will negotiate drug pricing with manufacturers of GLP-1 medications on behalf of state Medicaid agencies and Medicare Part D plans. BALANCE will launch in Medicaid in 2026; participating states can join the model on a rolling basis, from May through December.
The BALANCE Model is anticipated to start in Medicare Part D in January 2027. Prior to the launch of the BALANCE Model, CMS plans to implement a separate Medicare GLP-1 payment demonstration beginning July 2026 that will serve as a short-term bridge to the BALANCE Model.
NCPA has suggested that any model includes a specific ingredient cost reimbursement that covers the cost of the drug and its unique handling and storage requirements, as well as a commensurate professional dispensing fee, consistent with those used by Medicaid fee-for-service programs. We offered data to CMS to support our recommendations. Stay tuned for further updates as details of this model become available. This is a groundbreaking opportunity, as CMS can require specific payment to pharmacies for these drugs, especially in the Medicare Part D program, where PBM payment for them is currently unsustainable. For more information from CMS, click here.
