Late last year, the Centers for Medicare and Medicaid (CMS) announced the creation of two demonstrations, the longer term Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) model and the initially short term “Medicare GLP-1 Bridge,” which sought to expand access to GLP-1 weight-loss medication under the Medicare Part D programs. Last month, CMS announced they would not move forward with the BALANCE model and would extend the Bridge demonstration to a period of 18 months. In May, CMS announced additional information regarding the implementation of the Bridge demonstration.
Here’s What You Need to Know
➔ The Medicare Bridge Demonstration will begin July 1, 2026 and go until December 31, 2027.
➔ Eligible Medicare beneficiaries will be able to access certain GLP-1 Medications for $50. The $50 copay will not count toward the Part D deductible, nor does it count towards the annual $2,100 out-of-pocket cap on prescription drug costs.
➔ The $50 copay is only for weight loss. If you already take a GLP-1 for Type 2 diabetes, cardiovascular disease, or sleep apnea, you’ll continue to access your medication through your Part D plan.
➔ In order to access these medications, you must be enrolled in a Medicare Part D plan, which covers prescriptive drugs. You also must have a body mass index (BMI) of 27 and have a comorbid condition, or a BMI of 35 or higher.
➔ The demonstration provides coverage for the injectable formulations of Wegovy, the KwikiPen formulation of Zepbound, and the Foundayo pill.
➔ The prescription process under the Bridge Demonstration is slightly unusual. Instead of going through your Part D plan, you will need prior authorization. Your doctor will send the prescription to a central system. Once approved, you will be able to pick up your prescription for $50 at your pharmacy.
➔ Doctors do not need to be enrolled Medicare providers to write a prescription or submit a prior authorization request.
Resources
➔ CMS: Medicare GLP-1 Bridge
➔ CMS Press Release: Coming Soon: CMS to Provide $50 Monthly Access to GLP-1 Medications for Medicare Beneficiaries
➔ NPR: A new Medicare option for weight loss drugs is coming: Here’s what to know
