The Trump administration is delaying a voluntary model that aimed to expand access to GLP-1s in Part D after pushback from insurers.
The Centers for Medicare & Medicaid Services first announced the Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth, or BALANCE, model in December. Under the program, the agency would negotiate lower prices for GLP-1s in exchange for standardized coverage terms.
While the model will move forward in Medicaid and could launch as early as next month, plans to roll out BALANCE in Medicare Part D have been pushed back from a January 2027 start date based on insurer feedback. Abe Sutton, director of the Center for Medicare and Medicaid Innovation, told Endpoints News that plans were concerned about instability in Part D and felt they lacked the full picture of utilization under the model.
As a result, CMS will extend its "bridge" model through the end of 2027. Under the GLP-1 bridge, Part D beneficiaries can access key medications starting on July 1. Payers had until Monday to affirm their participation in BALANCE.
The bridge program operates outside of the Part D plan's usual payment flow, so insurers do not have to opt in and will not carry risk for drugs furnished under the model, CMS said on its website.
On the site, CMS said the delay will allow the agency "to collect additional data on GLP-1 utilization to share with Part D plan sponsors ahead of potential implementation of BALANCE in Part D."
The White House reached pricing deals with Eli Lilly and Novo Nordisk—manufacturers of the leading GLP-1 products—in November, with both drugmakers agreeing to selling the medications at a lower cost in the United States.
That pricing reassurance wasn't enough for health plans to jump in, however. Sutton told Endpoints that discussions with payers about the model are ongoing, and did not offer a timeline for when BALANCE could roll out in Part D beyond the bridge extension.
The model was discussed on UnitedHealth Group's earnings call Tuesday, with Bobby Hunter, CEO of government programs for UnitedHealthcare, saying there were still industry concerns about the model that have yet to be addressed.
“We’d like to find a path to yes there on coverage over time, but there are some notable challenges and outstanding questions with the currently planned structure,” Hunter told investors.