What Happened:
CMS launched the BALANCE Model in late 2025, opening a voluntary track for state Medicaid agencies to start GLP-1 coverage as early as May 2026. State agencies can join through January 1, 2027, and participating manufacturers agreed to a net price of $245 per 30-day supply on the model's covered drugs.
The Medicare GLP-1 Bridge starts July 1, 2026 and runs through the end of 2027, capping eligible Medicare Part D beneficiaries at a $50 monthly copay for covered GLP-1s.
Self-insured employer plans don't get BALANCE rates directly, but they inherit the public-sector benchmark in every renewal conversation, every PBM negotiation, and every internal coverage-decision memo between now and fall 2027.
More Insight:
The BALANCE Model is voluntary for states, manufacturers, and plans, and its drug list covers all formulations of Foundayo, Mounjaro, Ozempic, Rybelsus, and Wegovy, plus the KwikPen version of Zepbound. The $245 net price is the rate for Medicare in 2027 and, per the White House, the same rate for currently marketed injectables. Every Medicaid GLP-1 beneficiary also gets a manufacturer-funded lifestyle support program, which is going to show up in every benefits-vendor pitch this year.
From July 1, eligible Medicare Part D beneficiaries pay $50 a month for Foundayo, Wegovy, or KwikPen Zepbound when prescribed for weight reduction. Wegovy's list price still sits around $1,300 a month for cash-pay patients, so the gap between the bridge copay and the sticker is the comparison HR teams will be asked to explain.
Employer plans are starting from a wide range. KFF's 2025 Employer Health Benefits survey found that 43% of firms with 5,000 or more employees cover GLP-1s for weight loss, nearly all with prior authorization, with typical employee copays in the $25 to $75 range. Smaller employers cover less. GLP-1s are also one of the fastest-growing line items in pharmacy spend, and finance teams have been pushing back on coverage scope for two years already.
Self-insured plans don't pay BALANCE rates, but PBMs are about to pitch every plan sponsor on GLP-1 carve-outs, tighter prior-auth criteria, lifestyle-program tie-ins, and tiered eligibility that map loosely to what the public sector is doing. The leverage equation shifts as soon as the $245 number is publicly attached to a federal program.