On December 23, 2025, the Centers for Medicare & Medicaid Services (CMS) announced the BALANCE Model — a new program that, for the first time, will cover GLP-1 weight loss medications for eligible Medicare and Medicaid patients. CMS has since finalized drug pricing, published eligibility criteria, and set deadlines for states and insurance plans to sign up. The path forward is clear enough that your practice can start preparing today.

If GLP-1s have been out of reach for your Medicare and Medicaid patients because of cost, that is about to change. Practices that get their documentation and workflows in order now will be ready to serve those patients from day one. 

What BALANCE is and why it matters for your practice

The BALANCE Model allows CMS to negotiate GLP-1 drug prices directly with manufacturers on behalf of Medicare and Medicaid programs. This means lower-cost access to medications like Ozempic, Wegovy, and Mounjaro for patients who previously couldn't afford them.

One important thing to know: expanded coverage doesn't mean every patient automatically qualifies. Coverage depends on whether your state's Medicaid program and your patients' Medicare Part D plans opt in, and patients will still need prior authorization. This model doesn't guarantee coverage for any individual patient — but it opens the door for many who currently have none.

Which medications are included

CMS has negotiated with Eli Lilly and Novo Nordisk. The medications covered under BALANCE, for both diabetes management and weight loss, are: 

• Mounjaro (all formulations)
• Ozempic (all formulations)
• Rybelsus (all formulations)
• Wegovy (all formulations) 
• Zepbound KwikPen
• Orforglipron tablet (once FDA-approved)

For weight loss specifically, Medicare patients will pay a net price of $245 per 30-day supply under the full BALANCE Model starting in 2027. Medicaid pricing varies by state.

All patients receiving GLP-1s for weight management will also receive a free lifestyle support program through the manufacturer — meaning there's a natural connection point for your clinical team to reinforce healthy behavior change alongside medication management.

Which patients are eligible: what you need to document

To qualify, patients must meet one of these clinical criteria:

• BMI 35 or higher (age 18+) — no additional diagnosis needed
• BMI 30 or higher (age 18+) — with type 2 diabetes, moderate-to-severe sleep apnea, or a specific liver condition (noncirrhotic MASH with moderate-to-advanced fibrosis)
• BMI 27 or higher (age 18+) — with pre-diabetes, prior heart attack, prior stroke, or symptomatic peripheral artery disease

For Medicare patients specifically, the GLP-1 Bridge (launching July 1, 2026) adds a few more qualifying conditions for the BMI 30+ group: heart failure with preserved ejection fraction, uncontrolled high blood pressure despite two medications, or chronic kidney disease stage 3a or above.

As the prescribing provider, you'll also need to confirm that the patient is using the medication for weight management alongside lifestyle changes. You can start identifying patients in your panel who likely meet these criteria right now, before coverage launches.

In Healthie: Use Client Tags to organize patients by BMI range, relevant diagnosis, and payer type (Medicare vs. Medicaid). Tags are searchable across your full client list, so when coverage becomes available in your state, you can reach out to eligible patients immediately rather than hunting through individual charts.

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When coverage is coming: your timeline at a glance

Coverage rolls out in phases, so your key dates will depend on your patient mix. Here's what to put on your calendar: 

• May 1, 2026: Medicaid coverage begins rolling out. States can join through December 2026; the application deadline for state Medicaid agencies is July 31, 2026.
• July 1 – December 31, 2026: The Medicare GLP-1 Bridge launches. This is a short-term program giving eligible Medicare patients early access to certain GLP-1s at a $50/month copay, ahead of the full program in 2027. Eligible drugs include Foundayo (all formulations), Wegovy (injection and tablet), and Zepbound (KwikPen only).
• January 1, 2027 – December 31, 2031: The full BALANCE Model begins for Medicare Part D plans.

One thing to watch for starting April 30, 2026: The full Medicare Part D program only moves forward if at least 80% of Part D beneficiaries are enrolled in participating plans. CMS will announce whether that threshold was met by April 30, 2026.

Prior authorization: a workflow change you need to know about

Under the standard Medicare process, prior authorization requests go through the patient's insurance plan. Under the Medicare GLP-1 Bridge, that's not how it works.

During the Bridge period (July–December 2026), prior authorization is managed centrally by CMS through a single contractor (Humana, via the LI NET infrastructure). Your team submits authorization requests directly to that contractor — not to the patient's Part D plan. If your staff assumes the usual workflow, requests may be routed incorrectly and access gets delayed.

CMS will publish detailed prior authorization instructions in Spring 2026. Keep an eye on the CMS Medicare GLP-1 Bridge FAQ page for those updates.

In Healthie: Create a dedicated Charting Template for GLP-1 and BALANCE visits. Set it up to prompt clinicians to document the key items needed for prior authorization: current BMI, qualifying diagnoses, clinical indication for the medication, and confirmation that the patient is engaging in lifestyle modification. Having a structured template means nothing gets missed during a busy clinic day — and incomplete documentation is one of the most common reasons authorizations are delayed or denied.

Documentation: start capturing the right data before coverage launches

A prior authorization is only as strong as the documentation behind it. Patients who come in asking about GLP-1 coverage need their relevant information captured accurately from the very first visit, including BMI, weight history, qualifying diagnoses, current medications.

In Healthie: Update your patient intake forms to collect BMI, weight history, qualifying diagnoses, and current medications. You can embed weight and BMI as Smart Fields directly in the intake form, so when a patient fills these out, the values automatically flow into their metrics graph and carry forward into future visit notes. You can also create a dedicated patient group for BALANCE-eligible patients with a tailored intake flow for that population, keeping things organized as volume picks up.

Ongoing monitoring: what payers will expect visit after visit

GLP-1 coverage for weight management isn't a one-time authorization. Payers will expect documentation showing the patient is continuing to use the medication alongside lifestyle modification. If a patient stops the medication, you'll want a clear clinical note explaining why.

Week to week, this means each visit should contribute to a running clinical picture — not just a snapshot.

In Healthie: Healthie's Metrics Dashboard tracks weight, BMI, and custom metrics over time, displaying trends directly in each patient's profile for both you and the patient to see. You can create custom metrics for medication adherence, side effect tracking, and activity levels, and pull them into your charting templates so every visit automatically adds to that longitudinal record. Healthie also connects with Apple Health, Fitbit, and iHealth scales to sync data automatically. 

What's still coming from CMS

A few details haven't been finalized yet:

• Full prior authorization documentation for the Medicare GLP-1 Bridge (expected Spring 2026)
• State-by-state announcements on Medicaid participation
• Confirmation that the 80% Part D enrollment threshold was met (expected April 30, 2026)
• Guidance on how patients will transition from the Bridge program to the full BALANCE Model in 2027

Your practice readiness checklist

Before coverage goes live, work through these steps:

1. Tag likely-eligible patients in Healthie by BMI range, qualifying diagnosis, and payer type (Medicare/Medicaid)
2. Update intake forms to collect BMI, weight history, qualifying diagnoses, and current medications
3. Build a GLP-1/BALANCE charting template that prompts documentation of all prior authorization requirements
4. Check which payers in your panel are participating and when their coverage starts
5. Confirm the correct prior authorization routing for Medicare GLP-1 Bridge patients (centralized through a CMS contractor — not the patient's Part D plan)
6. Set up ongoing monitoring metrics: weight, BMI, medication adherence, side effects, activity level

For the latest updates, bookmark the CMS BALANCE Model page and the CMS Medicare GLP-1 Bridge FAQ.

Editor's note (April 2026): This post was originally published in March 2026 and has been updated to reflect the April 6, 2026 addition of Foundayo to the Medicare GLP-1 Bridge eligible drug list following FDA approval.