Last updated: May 1, 2026

CMS's new BALANCE Model is expanding GLP-1 coverage to Medicare and Medicaid patients for the first time. Here's how to get your Healthie workflows ready before coverage goes live.

On December 23, 2025, the Centers for Medicare & Medicaid Services announced the Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) Model — a voluntary model designed to expand access to GLP-1 medications for weight management among Medicare and Medicaid beneficiaries. Since then, CMS has finalized drug pricing, published eligibility criteria, and set timelines for states, plans, and patients. The picture is clear enough to act on now.

If GLP-1s have been out of reach for your Medicare and Medicaid patients, that's changing. The organizations that get their documentation, intake, and monitoring workflows in order now will be ready to serve those patients from day one.

What BALANCE Is

BALANCE is designed to reach Medicare Part D and Medicaid beneficiaries who need GLP-1 medications for weight management but have historically lacked coverage. Federal law currently limits GLP-1 coverage for weight loss in Medicare entirely, and Medicaid coverage varies widely by state. BALANCE creates a path to access for both populations by having CMS negotiate pricing and coverage terms directly with manufacturers on behalf of participating states and Part D plans.

Participation is voluntary for drug manufacturers, state Medicaid agencies, and Medicare Part D plans.

Covered medications — both manufacturers, Eli Lilly and Novo Nordisk, have agreed to participate. The medications covered under BALANCE include:

• All formulations of Mounjaro, Ozempic, Rybelsus, and Wegovy
• The KwikPen formulation of Zepbound (single-dose vial and pen formulations are not included in the Medicare GLP-1 Bridge)
• Foundayo (all formulations)
• Orforglipron (tablet), if approved by the FDA

These are covered for both currently covered indications (e.g., type 2 diabetes) and weight management indications.

Pricing — manufacturers have agreed to a $245 net price per 30-day supply for Medicare. Medicaid pricing varies by state under confidential negotiated terms.

Coverage Timelines

Medicaid — Rolling from May 1, 2026

Medicaid coverage begins on a rolling basis starting May 1, 2026. State Medicaid agencies can choose a participation start date between May 1 and January 1, 2027. The deadline for the state Medicaid agency RFA is July 31, 2026, so states not yet participating still have time to apply.

Coverage in Medicaid depends on participation by both manufacturers and states. For participating states, coverage criteria are standardized — states may offer broader coverage but cannot make access criteria more restrictive than the CMS-negotiated terms.

For your Medicaid patients: if your state participates, eligible patients will have access to covered GLP-1s for weight management. Patients still require prior authorization. Coverage is not guaranteed for every individual — it depends on state and patient eligibility.

Medicare — GLP-1 Bridge Starting July 1, 2026

The Medicare GLP-1 Bridge runs July 1, 2026 through December 31, 2027. This is a short-term CMS demonstration program that provides eligible Medicare Part D beneficiaries early access to covered GLP-1s at a $50/month copay.

Eligible Bridge drugs (for weight loss): Foundayo (all formulations), Wegovy (injection and tablets), and Zepbound (KwikPen only).

The Bridge operates outside the standard Part D benefit — Part D sponsors do not need to opt in, and Part D plans do not carry financial risk for Bridge costs. CMS is using Humana (the current LI NET administrator) as the central processor for the Bridge.

Important distinction: if a provider prescribes a GLP-1 for an indication already coverable under basic Part D (e.g., Zepbound for sleep apnea, or Wegovy for cardiovascular risk reduction in patients with established CVD), that goes through the patient's Part D plan through normal channels — not through the Bridge. The Bridge is specifically for the weight loss indication.

Prior Authorization: A Key Workflow Shift

Under the Medicare GLP-1 Bridge, prior authorization does not go through the patient's Part D plan. CMS is using a single central processor (Humana/LI NET) to manage prior authorization, claims adjudication, and pharmacy payments. Prescribing providers submit requests to this CMS contractor — not to the patient's plan.

This is a routing difference that is easy to miss and critical to get right. If your team defaults to routing PA requests through the patient's Part D plan for weight loss indications, those requests will not be processed correctly under the Bridge.

Eligibility for the Bridge requires prior authorization attesting that:

• The patient is being prescribed the drug to reduce excess body weight
• The patient meets BMI and clinical diagnostic criteria (to be confirmed via CMS's final PA guidance in Spring/Summer 2026)

CMS will release additional detail on prior authorization processes for the Bridge. We will update this post when that guidance is published.

In Healthie: Build a charting template specifically for BALANCE and GLP-1 visits that prompts clinicians to document everything needed for prior authorization:

• Current BMI and weight
• Qualifying diagnoses and ICD-10 codes
• Clinical indication for GLP-1 use (weight management vs. covered indication)
• Attestation that the patient is on or will continue a lifestyle modification program

Use Smart Fields to connect your intake form to your charting template, so BMI, diagnoses, and other standard fields carry over automatically — no re-entry.

Lifestyle Support: What It Means for Your Practice

All beneficiaries receiving GLP-1s for weight management under BALANCE will have access to a lifestyle support program at no cost, provided by the participating manufacturer. This program offers education on maintaining weight loss and making positive health choices, available both during and after medication treatment.

This creates a natural integration point for your clinical team. Patients on GLP-1s through BALANCE will be enrolled in or offered a manufacturer lifestyle program — your role is to document that they are engaged in appropriate lifestyle modification as part of the clinical record and, where relevant, as part of PA criteria.

If your organization delivers structured lifestyle support services — nutrition counseling, behavioral coaching, weight management programs — BALANCE represents an expansion of your reachable patient population.

In Healthie:

• Use Programs to build structured lifestyle support tracks and assign them to BALANCE-eligible patients
• Document lifestyle counseling session notes using a dedicated charting template for each visit type
• Track patient engagement and goal progress using Goals within the patient profile

Setting Up Your Healthie Account for BALANCE

Step 1 — Identify Your BALANCE-Eligible Patients

Start building your eligible patient list now, before coverage goes live.

In Healthie:

• Use Tags to flag patients by eligibility: "BALANCE-Medicaid Eligible," "BALANCE-Medicare Eligible," and payer type (Medicare Part D / Medicaid)
• Build saved filters in your Client List to create quick-access views: patients with BMI ≥30 (or ≥27 with a qualifying comorbidity), separated by payer type
• Update your intake forms to collect or confirm: BMI, weight history, qualifying diagnoses (obesity, type 2 diabetes, hypertension, cardiovascular conditions), and current payer information

Step 2 — Build Your GLP-1 Charting Template

Create a dedicated charting template for GLP-1 and BALANCE visits. Include:

• BMI and weight (set as a Metric field so it populates the patient's Metrics graph automatically)
• Qualifying diagnoses with ICD-10 code fields (these auto-populate into your CMS 1500 claims)
• Clinical indication — weight management vs. another covered indication
• Prior authorization documentation — attestation fields for lifestyle modification
• Medication prescribed, dose, and start date
• Lifestyle modification plan — current program, referrals made, patient attestation
• Side effect monitoring — tolerance, GI symptoms, adherence notes

Use Smart Phrases to build reusable text blocks for your most frequently documented clinical scenarios — for example, standard language for PA attestations, lifestyle referral notes, or medication initiation documentation. Type . in any chart note to access your saved phrases.

Step 3 — Set Up Longitudinal Tracking via Metrics

BALANCE patients will need ongoing documentation of clinical response over time. Payers will expect a longitudinal clinical record, not just a snapshot.

In Healthie:

• Create Custom Metrics for: weight, BMI, blood pressure, HbA1c, and any additional markers relevant to your patient population
• Add these metrics directly to your GLP-1 charting template using the Metrics field — each visit's documentation automatically updates the patient's Metrics graph
• Healthie connects with Apple Health, Fitbit, and iHealth scales to sync data automatically from connected devices

Step 4 — Configure Intake for New BALANCE Patients

For new patients entering your practice specifically for GLP-1 access, build a BALANCE-specific intake flow:

• Add fields for: BMI and weight history, qualifying diagnoses, current medications (to screen for contraindications), payer type and plan name, and prior GLP-1 history
• Include a lifestyle modification assessment — document baseline activity level, dietary patterns, and readiness for change
• Use Smart Fields to automatically carry intake responses into your GLP-1 charting template so clinicians don't re-enter information at the first visit

Step 5 — Set Up Ongoing Monitoring Workflows

GLP-1 management requires sustained follow-up. Build this into your scheduling and task workflows.

In Healthie:

• Create a recurring appointment type for "GLP-1 Follow-Up" with your BALANCE charting template as the default
• Use Tasks to flag patients due for follow-up or PA renewal
• Set up appointment reminders and automated messaging to keep patients engaged between visits
• Use Visualize / Reports to pull a list of active BALANCE patients with their most recent weight, BMI, and last visit date for population-level monitoring

What to Watch For

Several details are still forthcoming from CMS:

• Full prior authorization guidance for the Bridge — CMS indicated this will be released Spring/Summer 2026. We will update this post when the guidance is published.
• State-by-state Medicaid participation announcements — the July 31, 2026 RFA deadline is still open; monitor your state Medicaid agency for confirmation.
• Future of the Medicare Part D BALANCE Model — the full BALANCE Model for Medicare Part D did not launch in January 2027 as originally planned, and CMS has not confirmed a new timeline. The GLP-1 Bridge covers access through December 31, 2027 while CMS evaluates next steps.

We're monitoring closely and will update this guide as new information becomes available.

Key Resources

• CMS BALANCE Model
• Medicare GLP-1 Bridge FAQs
• CMS press release (December 23, 2025)
• BALANCE Manufacturer RFA
• BALANCE State Medicaid RFA
• KFF analysis of the BALANCE Model (March 24, 2026)

Healthie help docs referenced in this article:

• Charting templates
• Smart Fields
• Smart Phrases
• Custom Metrics
• Metrics in charting templates
• Client Tags
• Client List and Management
• Intake Form Builder
• Programs
• Goals
• Tasks
• Reporting / Visualize
• Chat / Secure Messaging

Questions about setting up your Healthie workflows ahead of the July 2026 Bridge launch? Contact our team.

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