Lilly’s obesity medicines, including Zepbound and Mounjaro, will become available through U.S. government health insurance programs such as Medicare under a new CMS initiative, with most patients expected to pay no more than $50 per month starting in 2027
Written By: Sana Khan BPharm
Reviewed By: Pharmacally Editorial Team
The U.S. healthcare system provides government-supported insurance to millions of Americans through programs such as Centers for Medicare & Medicaid Services (CMS), which oversees Medicare and Medicaid.
Medicare primarily covers people aged 65 and older, while Medicaid supports healthcare coverage for individuals with limited income. Within CMS, the Center for Medicare and Medicaid Innovation (CMMI) tests new payment and care models designed to improve healthcare quality while reducing costs.
One such initiative is the BALANCE Model; a new program being developed by CMMI to improve patient access to obesity treatments while making them more affordable for government insurance programs.
On Monday, CMS released new implementation details for the BALANCE model, expanding access to obesity medicines developed by Eli Lilly and Company.
Under the program, beginning January 1, 2027, Lilly’s GLP-1 medicines Zepbound and Mounjaro will be available through participating Medicare Part D plans (Prescription drug coverage). The investigational oral therapy orforglipron may also be included if it receives regulatory approval.
A key feature of the initiative is a cap on patient costs. For most Medicare beneficiaries enrolled in participating plans, monthly out-of-pocket costs for these medicines will be limited to $50 after the deductible is met.
Before patients reach their deductible, cost sharing will be restricted to $245 per month plus a dispensing fee, helping create a more predictable and reduced financial burden for patients seeking obesity treatment.
However, CMS noted that while most Medicare Part D plans participating in the BALANCE model are expected to honor the $50 monthly cap, cost sharing may vary for beneficiaries enrolled in certain basic Part D plans.
Lilly said it plans to educate patients and physicians about plan options and cost-smoothing programs that may help patients access GLP-1 therapies at the lowest possible out-of-pocket cost.
The BALANCE model may also extend beyond Medicare. State Medicaid programs will be able to apply to participate starting May 1, 2026, with implementation beginning on a rolling basis.
Obesity remains a major public health challenge in the United States, affecting more than 40% of adults and increasing the risk of conditions such as type 2 diabetes, cardiovascular disease, and certain cancers. By introducing cost controls and broader insurance coverage, the BALANCE model aims to improve access to modern obesity therapies that have shown substantial weight-loss benefits in clinical trials.
Lilly said it will continue working with CMS, health plans, healthcare providers, and pharmacists to expand access and affordability of obesity medicines for patients covered under Medicare.
Reference
Lilly’s statement on the CMMI BALANCE Model for GLP-1 medicines, 09 March 2026, Lilly’s statement on the CMMI BALANCE Model for GLP-1 medicines | Eli Lilly and Company
About Writer
Sana Jamil Khan is a B.Pharm graduate with a strong interest in medical writing and scientific communication. Her work focuses on interpreting clinical research, exploring developments in pharmaceutical science, and presenting complex medical information in a clear and accessible manner. She is particularly interested in topics related to human clinical studies, drug safety observations, and emerging therapeutic research.