BALANCE
Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth
The BALANCE Model aims to increase access to select GLP-1 medications and healthy lifestyle interventions for people with Medicare and Medicaid. CMS will negotiate drug pricing and coverage terms directly with manufacturers on behalf of state Medicaid agencies and Medicare Part D plan sponsors.
Innovation
CMS negotiates drug pricing and coverage terms directly with GLP-1 manufacturers on behalf of state Medicaid agencies and Medicare Part D plan sponsors.
The Problem
GLP-1 drugs for weight loss, along with lifestyle interventions, can help people improve their overall health, but GLP-1s are expensive and currently Medicare and Medicaid generally do not cover these drugs for the weight loss indication.
The Solution
Under BALANCE, CMS negotiates directly with GLP-1 manufacturers on behalf of state Medicaid agencies and Part D plans to lower the cost of these drugs, making them more accessible to people with Medicare and Medicaid.
Expected Outcomes
Helping people improve their metabolic health with GLP-1 treatment, along with access to lifestyle interventions, is a prevention approach that will improve people’s long-term health, potentially preventing chronic disease and disability.
Strategy
BALANCE empowers people with Medicaid and Medicare to meet their health goals by promoting evidence-based prevention.
Model Goals
- Increase access to select GLP-1 medications and healthy lifestyle interventions
- Lower the cost of GLP-1 drugs for weight loss
- Improve metabolic health and prevent chronic disease and disability
Patient Eligibility
People with Medicare and Medicaid who need GLP-1 medications for weight loss and metabolic health improvement.
- Must be a Medicare or Medicaid beneficiary
- Requires GLP-1 treatment for weight loss indication
Provider Eligibility
State Medicaid agencies and Medicare Part D plans can apply to participate in the model.
- Must be a State Medicaid agency or a Medicare Part D plan sponsor
Care Categories
Metabolic Health
CMS Benchmarks & Thresholds
operational
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