Eli Lilly (LLY) has said that monthly out-of-pocket costs for some Medicare enrollees taking its weight loss and obesity drugs could exceed the $50 cap under a new government-backed payment model.
The Centers for Medicare & Medicaid Services (CMS) announced the new coverage model known as Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) in December to lower the costs of GLP-1 drugs.
Under the voluntary program, the CMS will negotiate directly with manufacturers of GLP-1 drugs such as Lilly (LLY) and Novo Nordisk (NVO) so that most beneficiaries in participating Medicare programs will pay as little as $50 for a monthly supply of GLP-1s.
In a statement on Monday, Lilly (LLY) said that “while the majority of Medicare plan options will honor the $50 out-of-pocket cap, cost sharing will vary for beneficiaries in a small number of basic Medicare Part D plans.”
“We will be actively educating patients and their physicians about plan options and smoothing programs that can help patients access medications at the lowest possible out-of-pocket costs,” the company said.
The BALANCE Model is set to take effect for Medicaid as early as May 2026 and for Medicare Part D in January 2027.