CMS Provides Details for “Medicare GLP-1 Bridge” Coverage for Eligible Part D Beneficiaries

On Tuesday, March 3, 2026, the Centers for Medicare and Medicaid Services (“CMS”) released Frequently Asked Questions  (“FAQs”) that address certain details of a bridge program that will provide coverage of two GLP-1 medications (Wegovy® and Zepbound®) to qualified Medicare Part D beneficiaries when prescribed for weight loss (the “Bridge Program”) before the launch of the Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (“BALANCE”) Model, which is set to kickoff through participating Part D plan sponsors at the beginning of 2027.

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. 

Currently, Medicare and Medicaid generally do not cover GLP-1 medications for weight loss management, due to a statutory exclusion of coverage of drugs when used for weight loss or weight gain. However, the BALANCE Model, a CMS Innovation Center payment and service delivery model adopted under Section 1115A of the Social Security Act, is designed to fill this gap and provide eligible Medicare and Medicaid beneficiaries with coverage of these drugs for weight loss purposes. Medicaid state agencies can join the BALANCE Model beginning in May 2026 and Part D plan sponsors can opt into the model beginning in January 2027. 

When CMS announced the BALANCE model, it also indicated that it would develop the Bridge Program so that Medicare Part D beneficiaries can begin accessing GLP-1 drugs by mid-2026, before the launch of the BALANCE model for Part D plan sponsors. 

Details from the New FAQs

The FAQs now provide more insight into how the Bridge Program will operate and confirm that the program will only last for six months: from July 1, 2026 through December 31, 2026. Yet unanswered questions regarding this program remain, and the FAQs note that further information will be released in spring 2026. 

Below are key details from the FAQs:

Program will operate outside of Part D

Part D plan sponsors will not be directly involved in the Bridge Program. Instead, CMS will use a “single central processor” for administrative functions, including prior authorization, claims adjudication, and pharmacy payment. The FAQs do not identify who the “single central processor” will be. 

Coverage for Wegovy® and Zepbound® 

CMS states that, “at this time”, the GLP-1 drugs which will be eligible for coverage under the Bridge Program will be Wegovy®  (injection and tablets) and Zepbound®. 

Beneficiaries must be enrolled in a Part D plan

Medicare Part D beneficiaries must be enrolled in a Part D PDP or MA-PD plan for calendar year 2026 to qualify to receive GLP-1s under the Bridge Program.

Beneficiaries must meet certain prior authorization criteria

For a Part D beneficiary to qualify for coverage, a medical provider must submit with the prescription a prior authorization request that attests the beneficiary meets the following criteria:

• The GLP-1 drug is prescribed “to reduce excess body weight and maintain weight reduction in combination with current and ongoing lifestyle modification including structured nutrition and physical activity consistent with the applicable FDA approved label”;
• The beneficiary is at least 18 years old; and
• The beneficiary meets one of the following criteria at the start of GLP-1 therapy:
  • BMI greater than or equal to 35;
  • BMI greater than or equal to 30 with a diagnosis of at least one of the following: (a) heart failure with preserved ejection fraction; (b) uncontrolled hypertension, which is a systolic blood pressure above 140 mm Hg or diastolic blood pressure above 90 mm Hg while on two antihypertensive medications; or (c) chronic kidney disease stage 3a or above; or
  • BMI greater than or equal to 27 with a diagnosis of at least one of the following: (a) pre-diabetes, as defined by American Diabetes Association guidelines; (b) prior myocardial infarction; (c) prior stroke; or (d) symptomatic peripheral artery disease.

The FAQs do not indicate whether or how beneficiaries or their providers may appeal denials of prior authorization requests, but CMS will provide additional information on prior authorization processes in “Spring 2026”.

Coverage unavailable when GLP-1 “coverable” under Part D benefit

Beneficiaries who are prescribed Wegovy® or Zepbound® “for a use that is coverable under the basic Medicare Part D benefit, regardless of whether the drug is on the Part D plan’s formulary” (e.g., Zepbound® for the treatment of moderate to severe obstructive sleep apnea in adults with obesity, or Wegovy® to reduce the risk of major adverse cardiovascular (CV) events in adults with established CV disease who are either obese or overweight), will not qualify for coverage of that drug under the Bridge Program. Part D plan sponsors must continue to follow their existing formulary exception processes for these requests, and CMS will be monitoring to ensure plans do not shift coverage from the Part D benefit to the Bridge Program. The FAQs do not indicate how the central processor will determine if this exclusion applies, or whether a plan coverage determination that the GLP-1 will not be covered under the plan will be deemed sufficient to indicate it does not apply.

Copay applies

Beneficiaries will pay a $50 copay, which must be collected by the dispensing pharmacy. 

No Opt-In for Pharmacies

Pharmacies do not need to take any steps to opt-in into the Bridge Program.  CMS has created a specific Bank Identification Number (BIN) and Processor Control Number (PCN) for the Bridge Program (028918 MEDDGLP1BR), and will provide pharmacies with further guidance in the coming months regarding claims processing, including when to submit a claim to the central processor as opposed to a beneficiary’s plan.

Pharmacy reimbursement based on WAC plus unspecified dispensing fee

The central processor will reimburse pharmacies at “no lower than” the wholesale acquisition cost (WAC) of the drug, less the $50 copay, plus a dispensing fee, and, where applicable, sales tax. The FAQs do not indicate the amount of the dispensing fee or if or by how much ingredient cost reimbursement would be greater than WAC. Timing and mechanics for payment by the processor are not specified.

CMS will pay $245 for a monthly supply

CMS will pay a net price of $245 per monthly supply for GLP-1s under the Bridge Program. Presumably, this means that the manufacturers will pay CMS or its contractor rebates that equal the difference between the WAC and $245 for each 30-day supply.

After 2026 beneficiaries need to enroll in Part D plan that opts into BALANCE to maintain access

Due to the short-term nature of the Bridge Program, Part D beneficiaries who desire to maintain access to GLP-1s for weight loss management in 2027 will need to enroll in a Part D plan that opts into the BALANCE Model. 

Demonstration Program

CMS indicates that the Bridge Program will be operated as a demonstration program, in conjunction with the BALANCE model. 

Reed Smith will continue to track developments with regard to implementation of the Bridge Program and BALANCE model. If you have questions, please do not hesitate to reach out to the authors of this post, or the Reed Smith attorney with whom you work.