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Heres what it means for Medicaid enrollees: Medicaid access through the BALANCE Model could begin as early as May 2026 States must opt in voluntarily its not automatic Participating states receive federally negotiated prices from Eli Lilly (Zepbound, Mounjaro) and Novo Nordisk (Wegovy, Ozempic) Wegovy and Zepbound starting doses would cost the program $350/month (reduced from over $1,000) Patients in participating states would pay $50/month for covered GLP-1s Prior authorization and qualifying criteria will still apply This is the biggest potential expansion of GLP-1 access for Medicaid enrollees in history but it depends on your state deciding to participate

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As utilization has grown, they have become a major driver of pharmacy spend and overall health plan costsparticularly when used for weight loss rather than diabetes