Coverage Initiative for GLP-1 Medications in Medicare
On March 3, 2026, the Centers for Medicare and Medicaid Services (CMS) released a set of Frequently Asked Questions (FAQs) elucidating the operational details of a temporary coverage initiative for two GLP-1 medications, Wegovy® and Zepbound®. This "Bridge Program" is intended to offer coverage for eligible Medicare Part D beneficiaries prescribed these medications for weight loss, preceding the full implementation of the Better Approaches to Lifestyle and Nutrition for Comprehensive Health (BALANCE) Model, which is slated to commence in 2027 through participating Part D plan sponsors.
Introduced in December last year, the BALANCE Model is structured to enable price negotiations directly between CMS and pharmaceutical manufacturers on behalf of Part D plan sponsors and Medicaid agencies, aiming for more favorable terms for GLP-1 drugs. Currently, Medicare and Medicaid do not cover these medications specifically for weight loss due to statutory restrictions. The BALANCE Model, operating under Section 1115A of the Social Security Act, intends to address this gap, providing coverage for weight loss use in early 2027, with Medicaid agencies participating from May 2026 and Part D plan sponsors from January 2027.
To ensure transitional access to these medications before the BALANCE Model is fully deployed, CMS has devised the Bridge Program. The recent FAQs offer further insight into this initiative, indicating a six-month operation from July 1 to December 31, 2026, although more details are anticipated in the spring of 2026. Key elements include the involvement of a centralized administrator for managing claims and authorizations, though CMS has withheld the identity of this entity. At this stage, Wegovy® and Zepbound® are the covered medications.
Eligibility parameters require beneficiaries to be enrolled in a Medicare Part D prescription drug plan (PDP) or a Medicare Advantage plan that includes prescription drug (MA-PD) coverage for 2026. Physicians will be required to submit a prior authorization to confirm eligibility criteria. Significantly, the program excludes medications already covered under the basic Medicare Part D benefit for conditions like severe obstructive sleep apnea or cardiovascular risk reduction, leaving certain exclusions unexplained by the central processor.
For the dispensing process, pharmacies will collect a $50 copayment from beneficiaries, with CMS assigning a distinct Bank Identification Number (BIN) and Processor Control Number (PCN) for processing claims through the Bridge Program. Pharmacies will receive reimbursement at the wholesale acquisition cost minus the copayment, along with an undisclosed dispensing fee. This structure suggests a net cost of $245 per 30-day supply for CMS after incorporating manufacturer rebates, highlighting a focus on cost management for short-term medication access.
Beneficiaries desiring to continue these medications beyond December 2026 will need to enroll in a Part D plan compliant with the BALANCE Model. The Bridge Program acts as a demonstration project, complementing the larger BALANCE initiative. Reed Smith will continue to provide updates on the progress of the Bridge Program and the BALANCE Model. For inquiries, stakeholders are encouraged to contact the authors or their usual Reed Smith contact.