The BALANCE program was announced by the Center for Medicare and Medicaid Innovation (CMMI) in Late 2025 and is intended to expand access to GLP-1 therapies and related interventions for members with obesity and associated comorbidities. CMS later released a Request for Applications in March 2026 to Part D Plan Sponsors which provided several key clarifications, including:
• Coverage criteria standards patients must meet to be eligible
• Payment effectuation, including the creation of a Facilitated DIR (FAD) field in the PDE
• Participation thresholds required to be met for the program to move forward for Medicare Part D in 2027
Given the newly released coverage standards and detailed indicator requirements, it is important to evaluate not only how eligibility is expanding, but also how newly eligible members compare to those already eligible in terms of cost and risk profile. This paper will attempt to assess those relationships using recent experience data and to identify any insights that may inform future program participation strategy or plan design. For purposes of interpreting results, it is worth clarifying that this study does not attempt to adjust for program changes in 2027 such as shifts in plan liability, risk model changes, or changes in net drug cost.
