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Key Takeaways Prescribers and pharmacies will submit prior authorization requests and claims to a CMS contractor, not Part D plans or their PBMs Detailed conditions for beneficiary eligibility specified Patients will have a copay of $50, but pharmacy reimbursement details remain to be specified Background on the BALANCE Model CMS announced the BALANCE Model in December of last year, in which CMS will negotiate directly with manufacturers on behalf of Part D plan sponsors and state Medicaid agencies for more favorable costs and terms for GLP-1 medications

On just the Hims & Hers platform alone, nearly 80,000 individuals have shared they cannot access branded GLP-1 medications