Eli Lilly disclosed that a small number of basic Medicare Part D drug plans may not adhere to the $50‑per‑month out‑of‑pocket cap that the Centers for Medicare & Medicaid Services (CMS) has set for its obesity medicines under the BALANCE model, which will take effect on January 1 2027.
Under the BALANCE model, beneficiaries who meet their deductible will pay a maximum of $50 per month for Lilly’s weight‑loss drugs, while those who have not yet met the deductible face a $245 monthly cap plus a dispensing fee. Medicare Part D also imposes an annual out‑of‑pocket limit of $2,100 in 2026, after which the plan covers 100% of covered prescriptions.
The announcement signals that a handful of basic plans may allow patients to pay more than the capped amount, potentially raising out‑of‑pocket costs for some beneficiaries and affecting the affordability and uptake of Lilly’s obesity portfolio. The change is a direct regulatory development that could influence pricing dynamics and reimbursement for the company’s obesity medicines.
Eli Lilly’s Q4 2025 results, released the same day, showed revenue up 43% year‑over‑year to $19.3 billion and earnings per share up 51% to $7.39. The company guided 2026 revenue to $80‑$83 billion, a 25% increase at the midpoint versus 2025, and highlighted the strong sales of Mounjaro and Zepbound, which grew 110% and 123% respectively. The company’s competitive position against Novo Nordisk, which is facing pricing pressures, further underscores the significance of the Medicare coverage change.
The regulatory announcement is a material event that could reshape reimbursement and market access for Lilly’s obesity drugs. It is a new development, not a duplicate, and the article now contains the specific details required for a comprehensive report.
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