Today, the Centers for Medicare and Medicaid Services issued new implementation details for the Medicare and Medicaid CMMI BALANCE Model, marking a significant milestone in delivering on the commitment Lilly made with the U.S. government to expand access to our medicines and lower costs for patients. Beginning January 1, 2027, Lilly’s Zepbound\u00ae (tirzepatide), Mounjaro\u00ae (tirzepatide) and orforglipron, if approved, will be available through Medicare Part D participating plans under this program, with most beneficiaries having out-of-pocket costs capped at $50 per month after the deductible is met. Additionally, before patients reach their deductible, their cost sharing will be limited to $245 per month plus dispensing fee. State Medicaid programs can apply to participate beginning May 1, 2026, with a rolling start.<\/p>\n
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.<\/p>\n
The CMMI BALANCE Model builds on the Medicare GLP-1 Bridge Model, which enables Medicare Part D beneficiaries to access medications, including Zepbound\u00ae (tirzepatide) and orforglipron, if approved, at no more than $50 per month with no deductible effective July 1, 2026 through the December 31, 2026.<\/p>\n
Lilly will continue working with CMS, health plans, providers, and pharmacists to extend that access and affordability to every Medicare patient who needs these medicines.<\/p>\n
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