CMS BALANCE Model Participating Plans: Status, Plan List, and What to Do Next (April 2026)

Are there CMS BALANCE Model participating plans right now?

We want to make this part really clear because there's a lot of misinformation floating around right now: pages telling you to switch Part D plans for “BALANCE access,” brokers selling 2027 plans on the promise of $50 GLP-1s, news articles dated December 2025 that make it sound like January 1, 2027 is going to be a bright line moment for Medicare obesity coverage. None of that is the current reality.

What the April 21, 2026 CMS memo actually said

CMS sent the announcement to plan sponsors via a Health Plan Management System (HPMS) email — the channel the agency uses for binding operational guidance to Medicare plan sponsors. As reported by AHA News and confirmed by Avalere Health, the substance was clear: the Part D leg of BALANCE will not launch in calendar year 2027 “pending further evaluation and data collection.” Plan sponsors were specifically instructed not to indicate BALANCE participation in HPMS or in their Bid Pricing Tool submissions for CY 2027.

In plain English: there is no plan list to publish because there are no participating plans to put on it.

The Medicare GLP-1 Bridge, originally scheduled to end December 31, 2026, was simultaneously extended through December 31, 2027 — giving Medicare beneficiaries continuous access to FDA-approved weight-loss GLP-1s at $50 per month for an additional 12 months while CMS rethinks Part D-based coverage.

The 80% threshold — and why most insurers walked away

CMS conditioned the Part D launch on a “critical mass” of plan participation. The 80% threshold was an enrollment-weighted calculation: projected beneficiary enrollment in applying Part D plans, divided by total Part D enrollment (the RFA excluded SNPs and EGWPs from the threshold math even though those plans were eligible to participate). Applications closed April 20, 2026. The threshold was missed.

Industry analysis from Avalere Health and Optum / Advisory Board points to several drivers:

• Bid timing pressure. Part D bids for 2027 were due June 1, 2026 — leaving plans roughly six weeks after the application deadline to model the financial impact of expanded GLP-1 coverage. With no historical claims data on weight-loss GLP-1 use in Part D (because Medicare has been statutorily prohibited from covering weight-loss drugs since 2003), plans had no reliable way to project utilization or premium impact.
• Adverse selection risk. A plan that opted in might attract a disproportionate share of beneficiaries seeking GLP-1 coverage, concentrating cost without offsetting revenue.
• Maximum Fair Price (MFP) overlap. Semaglutide products (Ozempic, Rybelsus, Wegovy) are on the Medicare Drug Price Negotiation Program list with MFPs taking effect in 2027. The interaction between BALANCE pricing and MFP pricing required statutory waivers that didn't fully resolve plans' accounting concerns.

The result: enough plans declined that CMS couldn't launch the model.

Don't waste time hunting for a list — here's the path that actually exists

If you've been calling Part D plans asking whether they “joined the Bridge” or whether they're a “BALANCE plan,” save the phone time. The Bridge is administered directly by CMS through Humana as the central processor; plans don't opt in. Your Part D enrollment matters for one reason: you have to be in an eligible plan type to qualify for Bridge access (we cover this exactly below). Beyond that, your individual plan has no role in approving, denying, or processing your Bridge prescription.

Does my Part D plan have to opt in to the Medicare GLP-1 Bridge?

This is the single most misunderstood thing about how the Bridge works, and it's where you can stop searching the second you internalize it. There is nothing your Part D plan needs to do for you to access $50/month Wegovy, Zepbound KwikPen, or Foundayo if you qualify. The plan is not the gatekeeper. CMS is.

What still matters is your plan type:

Beyond plan type, what matters is your eligibility under one of the three BMI/diagnosis tiers (covered below), the specific drug and formulation prescribed, and the prior authorization route. None of that runs through your Part D plan.

What changed on April 21, 2026 — the pause and the Bridge extension

On April 21, 2026, CMS paused the Medicare Part D component of the BALANCE Model for 2027 and extended the Medicare GLP-1 Bridge through December 31, 2027. The Medicaid component of BALANCE continues on its original schedule, with state applications open through July 31, 2026 and start dates between May 1, 2026 and January 1, 2027. Manufacturer agreements with Eli Lilly and Novo Nordisk remain in place.

The pause is significant but it isn't a cancellation. CMS's language — “pending further evaluation and data collection” — leaves the door open. The CY2028 Advance Notice, which CMS typically releases in January or February of the prior year, is the document to watch. If BALANCE language reappears there in substantive form, expect a relaunch attempt for plan year 2028.

Why this is actually better news for most beneficiaries than it sounds

This is the part that gets buried in the technical coverage. Under the original BALANCE plan:

• •The Bridge was supposed to end December 31, 2026.
• •To keep weight-loss GLP-1 coverage in 2027, you would have needed to be enrolled in a Part D plan that opted into BALANCE — meaning many people would have had to switch plans during Open Enrollment, with all the disruption that brings for non-GLP-1 medications, network pharmacies, and premiums.
• •If your plan didn't join, you'd have lost coverage on January 1.

Under the post-April-21 reality:

• ✓The Bridge runs through December 31, 2027 — 12 extra months of $50/month access.
• ✓You don't have to switch plans for 2027 to keep weight-loss GLP-1 coverage.
• ✓Your 2027 Part D plan choice can be based on what actually matters: how it covers your other medications.

There's a real downside — the Bridge is narrower than BALANCE would have been (Wegovy, Zepbound KwikPen, and Foundayo only), and the $50 copay doesn't count toward your Part D out-of-pocket cap. Both of those things would have been better under BALANCE. But on the question of whether your existing access continues, the extension is a quiet win.

Bridge vs. BALANCE vs. regular Part D — the only comparison you need

The Medicare GLP-1 Bridge is the active access path. Medicare Part D BALANCE is paused. Regular Part D continues to apply for GLP-1s prescribed for currently coverable indications like type 2 diabetes, cardiovascular risk reduction, or obstructive sleep apnea. These are three separate access paths with different rules, different drug lists, and different paperwork.

Sources: CMS Medicare GLP-1 Bridge FAQ; CMS BALANCE Part D RFA; KFF brief.

The distinction that matters most: the Bridge is the only path to Medicare coverage of GLP-1s prescribed solely for weight loss. If your prescription is for a currently coverable indication — Ozempic for type 2 diabetes, Wegovy for cardiovascular risk reduction in adults with established cardiovascular disease, Zepbound for obstructive sleep apnea in adults with obesity — that prescription goes through your regular Part D plan, with your regular plan's prior authorization and copay. The Bridge isn't relevant to those prescriptions.

Which GLP-1 medications are covered (and which are NOT)

Bridge formulation eligibility matrix

The Ozempic question we have to answer every week

We get asked this constantly: “Ozempic and Wegovy contain the same active ingredient — can I get Ozempic through the Bridge if my doctor prescribes it?” No. Despite the same active molecule (semaglutide), Ozempic and Wegovy are different FDA-approved products with different approved indications, different dosing structures, and different NDC numbers. The Bridge drug list is by NDC. Ozempic for weight loss isn't Bridge-eligible because Ozempic isn't FDA-approved for weight loss.

If you have type 2 diabetes and your prescription for Ozempic is for that indication, you don't need the Bridge — your regular Part D plan covers it (subject to its formulary and prior authorization rules). That's actually a more flexible path because it counts toward your Part D out-of-pocket cap.

Bridge NDC reference (for your pharmacy if they're new to this)

If your pharmacist hasn't seen the Bridge yet, hand them this.

Source: CMS Medicare GLP-1 Bridge FAQ, last updated April 6, 2026.

Who qualifies for the Medicare GLP-1 Bridge — the three BMI pathways

To qualify for the Medicare GLP-1 Bridge, you must (1) be enrolled in an eligible Medicare Part D plan type, (2) be prescribed an eligible GLP-1 specifically for weight loss with ongoing lifestyle modification, and (3) meet one of three BMI/diagnosis tiers published in the CMS Bridge FAQ. You only need to meet one tier.

The three eligibility tiers

Source: CMS Medicare GLP-1 Bridge FAQ.

Quick BMI reference

The doctor visit cheat sheet

Bring this to your appointment so the prior authorization gets submitted correctly the first time. Common denials trace back to incomplete documentation in the chart at the time of the PA request.

• ✓Your current Medicare drug coverage type (PDP, MA-PD, SNP, EGWP, dual-eligible, LI NET).
• ✓Your medication preference (Wegovy injection, Wegovy tablets, Zepbound KwikPen, or Foundayo).
• ✓Your BMI at the time you intend to start the medication.
• ✓Documentation of your qualifying condition (Tier 2 or Tier 3 only).
• ✓Confirmation that the prescription is for weight loss with ongoing lifestyle modification (CMS-required attestation).
• ✓A note for your prescriber: the prior authorization goes to the CMS central processor, not to your Part D plan.

How prior authorization actually works (and why your Part D plan isn't involved)

This is the part that breaks the most pharmacist and provider workflows in the early days — the muscle memory is to send everything to a Part D plan. The Bridge changes the address.

The Bridge claim workflow, step by step

1. 1

   You confirm eligible plan type: PDP, MA-PD, SNP, EGWP, LI NET, or dual-eligible enrolled in one of the above.

2. 2

   Your provider confirms BMI/diagnosis criteria — one of the three tiers from the previous section.

3. 3

   Your provider writes the prescription for an eligible drug (Wegovy injection or tablets, Zepbound KwikPen, or Foundayo) for weight management.

4. 4

   Your provider submits the prior authorization to the CMS central processor — not to your Part D plan. CMS will release the specific submission portal details in spring 2026; your provider should monitor CMS guidance leading up to July 1, 2026.

5. 5

   Your pharmacy bills the Bridge using BIN 028918 and PCN MEDDGLP1BR. The pharmacy collects your $50 copay and is reimbursed through the Bridge claims process; participating manufacturers provide eligible Bridge drugs at a $245 net price per monthly supply under CMS terms.

6. 6

   You pick up your medication and continue with lifestyle modification as part of the program's core requirement.

When PA goes to your Part D plan instead of the central processor

The Bridge is specifically for weight-loss-only prescriptions. If your prescriber writes the GLP-1 for an indication that's already coverable under regular Part D — Zepbound for obstructive sleep apnea in adults with obesity, or Wegovy for cardiovascular risk reduction — the prior authorization follows your plan's normal process. Same drug, different paperwork, depending on what your prescription says.

The Bridge troubleshooting table

What it costs — and the LIS gotcha that affects low-income enrollees

Bridge cost in plain numbers

The damaging admission about the Bridge — and the upside

We're going to be straight with you: the Bridge is narrower than a fully launched BALANCE Model would have been. Under BALANCE, if it had launched in Part D for 2027 as planned:

• ✗The drug list would have been broader (Mounjaro, Ozempic, Rybelsus added to Wegovy / Zepbound KwikPen / Foundayo).
• ✗Cost-sharing would have integrated with the Part D out-of-pocket cap, meaning your spend would have helped you reach the $2,400 catastrophic threshold.
• ✗Low-income beneficiaries with LIS would have received their normal cost-sharing reductions.

The Bridge doesn't do any of those three things. But here's what the Bridge does do that BALANCE-2027 wouldn't have: it works regardless of which Part D plan you're in. It runs through December 31, 2027. It doesn't require you to switch plans during Open Enrollment. For most beneficiaries, that trade — narrower drug list and no TrOOP credit, in exchange for not having to switch plans and 12 extra months of access — works out fine.

What about the $1,600 figure people quote

A common pattern in public Medicare-focused forum threads: a beneficiary's doctor prescribes the Wegovy pill, the Part D plan denies it, and the cash-pay quote is around $1,600/month. That denial happens because regular Part D still excludes weight-loss-only prescriptions under the 2003 statute. The Bridge is the answer for a weight-loss-only Wegovy prescription starting July 1, 2026. If that beneficiary qualifies under one of the three BMI tiers, they go from a $1,600/month list price to a $50 copay — a $1,550 monthly difference. That's the size of the access change the Bridge is making for the people it covers.

What individual insurers actually said — the public statement tracker

Why the labels matter — and the editorial rule we follow on this page

• •A Bridge “participant” is meaningless in the sense most beneficiaries are looking for. The Bridge covers eligible beneficiaries regardless of which plan they’re in (provided the plan type is eligible). UnitedHealthcare saying they’ll participate in the Bridge is essentially a statement that they’re prepared operationally — but it doesn’t gate access for anyone else.
• •A “BALANCE participating plan” doesn’t currently exist because the Part D component isn’t launching. CVS/Aetna declining and UnitedHealthcare working toward “yes” both happened in a context where the model was still being negotiated; both became moot when CMS paused.
• •Humana’s central processor role is an administrative function, not a plan-coverage statement. You don’t have to be in a Humana plan to use the Bridge. Any pharmacist or insurance broker telling you otherwise is mistaken.

Which state Medicaid programs are participating in BALANCE

The Medicaid GLP-1 obesity coverage starting point (January 2026)

As of January 2026, 13 state Medicaid programs covered GLP-1s for obesity treatment under fee-for-service, down from 16 in October 2025, per KFF's analysis of 50-state Medicaid budget data. Four states removed coverage in early 2026: California, New Hampshire, Pennsylvania, and South Carolina. States that already cover obesity GLP-1s in Medicaid have a strong reason to apply to BALANCE because the negotiated supplemental rebates would lower their per-member cost.

How Medicaid BALANCE participation works (different from Medicare)

• •State agreements — Each participating state signs a State Agreement with CMS adopting standardized Medicaid Key Terms.
• •Supplemental rebate agreements — Participating states sign supplemental rebate agreements with each participating manufacturer, on top of statutory Medicaid Drug Rebate Program rebates.
• •Equal application — The Medicaid Key Terms apply equally in fee-for-service Medicaid and Medicaid managed care.
• •Floor, not ceiling — States cannot make eligibility more restrictive than the Key Terms but can offer broader coverage.
• •Member cost — Medicaid enrollees generally pay little or no copay for prescription drugs; the benefit is whether the drug is covered at all, not the copay amount.
• •Net pricing — The discounted Medicaid net price is confidential, not publicly disclosed.

State BALANCE participation tracker

We commit to populating this table state-by-state as agreements are publicly executed. Most cells will read “Status pending” through May; we expect meaningful state announcements to begin in June and accelerate through July.

If you're on Medicaid and trying to plan, your single most useful action is calling your state Medicaid agency directly and asking whether they've applied to BALANCE for obesity coverage and when they expect a decision.

What to do during 2026 Medicare Open Enrollment (October 15 – December 7, 2026)

The 2027 Open Enrollment checklist (when BALANCE is paused)

1. 1

   Inventory your medications. Make a complete list of every prescription you currently take, including dose and frequency.

2. 2

   Use Medicare Plan Finder (medicare.gov/plan-compare) to compare plans on coverage of your full medication list. Plug in every drug. The total annual cost projection is what matters, not the headline monthly premium.

3. 3

   For your GLP-1, check the indication. If your GLP-1 is purely for weight loss, the Bridge covers it regardless of plan. If it's for a covered indication (diabetes, CV risk reduction), the formulary still matters.

4. 4

   Check pharmacy network. Your current pharmacy may not be preferred under your 2027 plan.

5. 5

   Ignore plan marketing claiming “BALANCE coverage.” No 2027 plan offers BALANCE-style integrated GLP-1 weight-loss coverage because BALANCE Part D didn’t launch. This is a red flag from any broker or plan-finder tool.

6. 6

   Confirm your 2027 plan type is Bridge-eligible. PDP, MA-PD, SNP, EGWP, dual-eligible, and LI NET are all eligible.

7. 7

   Don’t switch carriers solely based on Bridge participation rumors. The Bridge doesn’t require plan participation. Carriers can’t differentiate themselves on Bridge “exclusivity” because there is no exclusivity.

When you should call your plan vs. when you shouldn't

What if you're not using Medicare Part D or Medicaid

The Medicare GLP-1 Bridge and the BALANCE Model only apply to people on government insurance (Medicare Part D or Medicaid). If you're on commercial insurance, uninsured, or self-paying — or you're under 65 without Medicare eligibility — your path runs through entirely different channels. (Note: Medicare isn't only for people 65+. People can qualify earlier due to disability, ESRD, or ALS. What determines whether the Bridge pathway applies is whether you're enrolled in eligible Medicare Part D or Medicaid coverage — not your age.)

The realistic options for people without Medicare or Medicaid:

• •Commercial insurance with weight-loss GLP-1 coverage. Some employer-sponsored plans cover Wegovy, Zepbound, or Foundayo for weight management with prior authorization. Coverage has tightened significantly in 2025 and 2026. Check your plan's formulary and PA criteria.
• •Manufacturer self-pay programs. LillyDirect (Zepbound, Foundayo, Mounjaro), NovoCare (Wegovy, Ozempic), and TrumpRx sell brand-name FDA-approved GLP-1s on a cash-pay basis without insurance involvement. Pricing varies by product and dose; verify each on the publish date before relying on a specific number.
• •HSA/FSA. Eligibility can depend on plan rules and documentation; check your administrator.
• •Telehealth providers with insurance concierge support. Telehealth platforms that prescribe FDA-approved GLP-1s and help with prior authorization or self-pay setup.

What we actually verified for this page

This page was built from primary CMS sources, cross-checked against the most recent policy analyses and reputable trade reporting, with each claim tied to a named source and a date.

Refresh cadence — what we re-verify and how often

Last verified: April 28, 2026. Next scheduled verification: May 12, 2026.

Frequently asked questions

Your next step

If you're still here, you've now seen what nobody else is saying clearly: there is no BALANCE participating Part D plan list to shop for in 2027, you don't need one, and the Bridge can cover your weight-loss GLP-1 access at $50/month through December 31, 2027 if you qualify — regardless of which eligible Part D plan you're in. Pick the path that matches your situation: