Medicare GLP-1 Bridge
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Overview
On December 23, 2025, the Centers for Medicare & Medicaid Services (CMS) announced the Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) Model and a separate short-term demonstration (now called the “Medicare GLP-1 Bridge”) that will begin in July 2026 and serve as a bridge to the BALANCE Model in Medicare Part D. Frequently asked questions (FAQs) related to the Medicare GLP-1 Bridge are below. CMS will provide additional information on the design of the Medicare GLP-1 Bridge in Spring 2026.
FAQs
Q: What is the Medicare GLP-1 Bridge? How is it different from the BALANCE Model?
A: Access to GLP-1 drugs for weight loss under the BALANCE Model will launch in Medicaid as early as May 2026 for states that opt to participate and in Medicare Part D in January 2027. However, CMS is providing eligible Medicare Part D beneficiaries with early access to certain GLP-1 drugs through a separate short-term demonstration that will serve as a bridge to the BALANCE Model.
The Medicare GLP-1 Bridge will operate outside of the Medicare Part D benefit’s coverage and payment flow, which means that Part D sponsors are not directly involved in the Medicare GLP-1 Bridge. As a result, Part D sponsors will not carry risk for eligible GLP-1 drugs furnished under the Medicare GLP-1 Bridge, and Part D sponsors do not have to opt in to the Medicare GLP-1 Bridge for eligible beneficiaries to access these drugs beginning July 2026. CMS will use a single central processor to manage prior authorization, claims adjudication, and payment to pharmacies for the Medicare GLP-1 Bridge.
However, to participate in the BALANCE Model starting January 1, 2027, Part D sponsors must apply and be approved to participate. CMS expects to release additional information about BALANCE Part D plan participation requirements and the application process in March 2026. The Medicare GLP-1 Bridge has no bearing on a Part D sponsor’s ability to participate in the BALANCE Model. CMS is exploring potential pathways for sharing data on GLP-1 drug utilization under the Medicare GLP-1 Bridge with Part D sponsors.
Q: Under what authority is CMS conducting the Medicare GLP-1 Bridge?
A: Section 402(a)(1)(A) of the Social Security Amendments of 1967, as amended and expressly made applicable to Part D by section 1860D-42(b) of the Social Security Act (“the Act”), authorizes the Secretary to carry out demonstration projects to determine whether “changes in methods of payment or reimbursement” under Medicare “would have the effect of increasing the efficiency and economy of health services” covered under Medicare through the “creation of additional incentives to these ends.” Pursuant to such authority, the Medicare GLP-1 Bridge will operate between July 1, 2026, and December 31, 2026.
Medicare GLP-1 Bridge Eligibility and Participation
Q: Are all Medicare beneficiaries able to receive GLP-1 drugs furnished via the Medicare GLP-1 Bridge?
A: The Medicare GLP-1 Bridge will be nationwide and available in all states and territories.
To qualify for coverage of eligible GLP-1 drugs via the Medicare GLP-1 Bridge, Medicare beneficiaries must meet certain prior authorization criteria and be enrolled in a standalone prescription drug plan (PDP) or Medicare Advantage (MA) coordinated care plan (i.e., HMO, HMOPOS, and Local and Regional PPO plans) that offers prescription drug coverage (MA-PD plans) in CY 2026.
Part D beneficiaries in Special Needs Plans (SNPs), employer/union group waiver plans (EGWPs), and the Limited Income Newly Eligible Transition (LI NET) program are eligible to participate. Beneficiaries enrolled in private fee-for-service plans, section 1876 cost contract plans, section 1833 health care prepayment plans, PACE organizations, fallback plans, and religious fraternal benefit plans are not eligible to participate, unless also enrolled in a standalone PDP, as applicable.
Additionally, dually-eligible beneficiaries who are enrolled in eligible Part D plan types and meet the prior authorization criteria will have access to GLP-1 drugs via the Medicare GLP-1 Bridge.
Q: What GLP-1 drugs will be available through the Medicare GLP-1 Bridge?
A: At this time, for the purposes of the Medicare GLP-1 Bridge, an eligible GLP-1 drug is any of the following products when used to reduce excess body weight and maintain weight reduction: Wegovy® (injection and tablets) and Zepbound®.
Q: How can a medical provider refer a beneficiary to the Medicare GLP-1 Bridge?
A: To access GLP-1 medications via the Medicare GLP-1 Bridge, an eligible beneficiary must have a medical provider submit a prior authorization request and a prescription for an eligible GLP-1 drug for a use covered under the demonstration. CMS will provide additional information on prior authorization processes in Spring 2026.
Q: Must a provider be enrolled in Medicare to prescribe an eligible GLP-1 product or submit a prior authorization request under the Medicare GLP-1 Bridge?
A: For the Medicare GLP-1 Bridge, as in the Part D program, a provider does not need to be enrolled in Medicare in order to write a prescription or submit a prior authorization request for products provided under the Medicare GLP-1 Bridge to an eligible beneficiary. However, the provider must not be on the Preclusion List in order for the drug to be coverable under the Medicare GLP-1 Bridge for an eligible beneficiary.
Q: What clinical criteria must a beneficiary meet in order to qualify for the Medicare GLP-1 Bridge?
A: For a beneficiary to qualify for the Medicare GLP-1 Bridge, a provider must submit a prior authorization request that attests the beneficiary meets the following criteria:
- The beneficiary is prescribed the requested drug 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, AND
- The beneficiary is at least eighteen (18) years of age and has a BMI greater than or equal to thirty-five (≥35) at the time of initiation of GLP-1 therapy, or
- The beneficiary is at least eighteen (18) years of age and has a BMI greater than or equal to thirty (≥30) at the time of initiating GLP-1 therapy with a diagnosis of one or more of the following: (A) heart failure with preserved ejection fraction, (B) uncontrolled hypertension (defined as systolic blood pressure above 140 mm Hg or diastolic blood pressure above 90 mm Hg, despite concurrent treatment with two antihypertensive medications), or (C) chronic kidney disease stage 3a or above, or
- The beneficiary is at least eighteen (18) years of age and has a BMI greater than or equal to twenty-seven (≥27) at the time of initiating GLP-1 therapy with a diagnosis of one or more of the following: (A) pre-diabetes (as defined by American Diabetes Association guidelines), (B) previous myocardial infarction, (C) previous stroke, or (D) symptomatic peripheral artery disease.
Q: Does a beneficiary need to meet the Medicare GLP-1 Bridge clinical criteria at the time of the prior authorization request, or at the time they first initiated GLP-1 therapy?
A: Eligible beneficiaries must meet the clinical criteria at the time of GLP-1 therapy initiation. This includes beneficiaries who initiated therapy prior to enrolling in Medicare Part D and/or prior to the July 1, 2026 launch of the Medicare GLP-1 Bridge.
For example, if a beneficiary initiated GLP-1 therapy in September 2024 with a body mass index (BMI) of 37 and has a BMI of 34 at the time of a July 2026 prior authorization request, the prescribing provider should attest that the beneficiary met the BMI ≥35 criterion at the time therapy was initiated.
Q: How will providers submit prior authorization requests for the Medicare GLP-1 Bridge?
A: CMS will be using a single central processor to manage prior authorization, claims adjudication, and payment to pharmacies for the Medicare GLP-1 Bridge. When a provider prescribes an eligible GLP-1 drug to an eligible beneficiary for a use covered under the Medicare GLP-1 Bridge, the provider will submit a prior authorization request to the central processor rather than to the eligible beneficiary’s Part D plan. CMS will conduct outreach and education to help providers understand when to submit a prior authorization request for an eligible GLP-1 drug to the beneficiary’s Part D plan versus the central processor.
When a provider prescribes a GLP-1 drug to a beneficiary for a use covered under the basic Part D benefit (e.g., Zepbound® for the treatment of moderate to severe obstructive sleep apnea (OSA) in adults with obesity; Wegovy® to reduce the risk of major adverse cardiovascular (CV) events in adults with established CV disease and either obesity or overweight), the provider will need to complete the applicable utilization management requirements through the beneficiary’s Part D plan.
Q: Who will serve as the central processor for the Medicare GLP-1 Bridge responsible for managing prior authorization, claims adjudication, and payment to pharmacies?
A: CMS will be utilizing Humana, the current administrator of the Limited Income Newly Eligible Transition (LI NET) program, as the central processor for the Medicare GLP-1 Bridge. The LI NET infrastructure provides the end-to-end operational capabilities and national scale that are critical to provide broad access to GLP-1 drugs to Medicare beneficiaries via the GLP-1 BRIDGE starting July 1, 2026.
Q: How will the central processor handle coordination of benefits and claims processing?
A: The Medicare GLP-1 Bridge will be the primary payer for products covered under the Medicare GLP-1 Bridge and will not coordinate benefits with other payers. Coupons and discount programs may not be applied to Medicare GLP-1 Bridge claims.
The central processor will process claims submitted electronically using the NCPDP Telecommunication Standard. Paper claims and direct member reimbursements will not be accepted by the central processor.
CMS expects to release additional operational guidance on pharmacy claims processing in Spring 2026.
Q: How will beneficiaries who participate in the Medicare GLP-1 Bridge transition to the BALANCE Model?
A: The Medicare GLP-1 Bridge is a short-term demonstration to provide eligible Medicare Part D beneficiaries with early access to certain GLP-1 drugs ahead of the launch of the BALANCE Model on January 1, 2027. To maintain access in 2027, beneficiaries who participate in the Medicare GLP-1 Bridge will need to enroll in a Part D plan for 2027 that has opted to participate in BALANCE for continued access to GLP-1 drugs for weight loss. CMS will provide additional information on the transition from the Medicare GLP-1 Bridge to the BALANCE Model in coming months, including planned beneficiary outreach and education.
Pharmacy Engagement in the Medicare GLP-1 Bridge
Q: Who can pharmacies contact to express interest in participating in the Medicare GLP-1 Bridge program?
A: Pharmacies do not need to opt-in to participate in the Medicare GLP-1 Bridge. CMS and the central processor will provide additional technical instructions on pharmacy claims processes for the Medicare GLP-1 Bridge in the coming months.
Q: Where will pharmacies send claims for the Medicare GLP-1 Bridge?
A: CMS has established a Bank Identification Number (BIN) and Processor Control Number (PCN) that is specific to the Medicare GLP-1 Bridge (028918 MEDDGLP1BR). A payer sheet with be forthcoming. CMS will conduct outreach and education to help pharmacists understand when to submit a claim request for an eligible GLP-1 drug to the beneficiary’s plan versus the central processor.
Q: How will claims be paid under the Medicare GLP-1 Bridge?
A: Pharmacies will collect a $50 copay amount from the eligible beneficiary, and the central processor will process payment to the pharmacy. Pharmacies will be reimbursed by the central processor at the wholesale acquisition cost of a drug, less the beneficiary copay, plus a dispensing fee and, as applicable, sales tax.
Note: This was updated on March 9, 2026 to clarify that the wholesale acquisition cost will be the standard reimbursement amount to pharmacies for products dispensed through the Medicare GLP-1 Bridge.
Part D Sponsor Interactions with the Medicare GLP-1 Bridge
Q: What should Part D sponsors do if they receive a prior authorization request for a Medicare GLP-1 Bridge-covered drug for weight management?
A: If a provider submits a prior authorization request to the Part D plan for a GLP-1 product that is not covered by the Part D plan but may be eligible for coverage under the Medicare GLP-1 Bridge, CMS strongly encourages the plan sponsor to return a message directing the provider to contact the central processor. CMS will work with the National Council for Prescription Drug Programs (NCPDP) to create a guidance document to help the industry implement the program within the adopted NCPDP standards; we anticipate the guidance will include standard messaging that plans should utilize with providers.
CMS reminds plan sponsors of their obligations related to coverage determinations under 42 CFR Part 423 Subpart M. The Medicare GLP-1 Bridge does not modify beneficiary appeal rights, including exception requests, in relation to their Part D coverage.
Q: How does the Medicare GLP-1 Bridge interact with drug coverage from a Medicare Part D plan?
A: Under the Medicare GLP-1 Bridge, participating manufacturers will provide eligible GLP-1 drugs at a net price of $245 per monthly supply. Coverage of eligible GLP-1 drugs furnished under the Medicare GLP-1 Bridge is provided outside of the Part D benefit payment flow and coverage. As such, no part of the $245 net price for eligible GLP-1 drugs prescribed for uses covered under the Medicare GLP-1 Bridge would count toward an eligible beneficiary’s gross covered prescription drug costs (GCPDC), and no part of the $50 copay would count toward the beneficiary’s true out-of-pocket costs (TrOOP) under their Part D plan. In addition, the $50 copay for eligible beneficiaries would remain the same, regardless of the phase of the Part D benefit an eligible beneficiary is in when they fill a prescription for an eligible GLP-1 drugs covered under the Medicare GLP-1 Bridge. Similarly, low-income cost-sharing subsidies would also not apply to any portion of the copay.
Beneficiaries who are prescribed an eligible GLP-1 drug for a use that is coverable under the basic Medicare Part D benefit, regardless of whether the eligible GLP-1 drug is on the Part D plan’s formulary (e.g., Zepbound® for the treatment of moderate to severe obstructive sleep apnea (OSA) in adults with obesity; Wegovy® to reduce the risk of major adverse cardiovascular (CV) events in adults with established CV disease and either obesity or overweight) would not qualify for coverage of that eligible GLP-1 drug under the Medicare GLP-1 Bridge. Part D plan sponsors must continue to follow their existing formulary exception processes for these requests. CMS will monitor Part D formulary and utilization management practices, including formulary exception processes, to ensure plans do not shift coverage or access decisions from the Part D benefit to the Medicare GLP-1 Bridge.
Interaction with the Medicare Drug Price Negotiation Program
Q: How does the maximum fair price (MFP) announced under the Medicare Drug Price Negotiation Program for Ozempic; Rybelsus; Wegovy relate to the Medicare GLP-1 Bridge?
A: Ozempic; Rybelsus; Wegovy is a selected drug for initial price applicability year 2027 of the Medicare Drug Price Negotiation Program (Negotiation Program). The MFP for Ozempic; Rybelsus; Wegovy, negotiated under the Negotiation Program, does not become effective until January 1, 2027. By contrast, the Medicare GLP-1 Bridge is a distinct, time-limited demonstration that will operate between July and December 2026. The two initiatives operate independently and on different timelines, and no products provided under the Medicare GLP-1 Bridge are subject to an MFP during the demonstration period.
Additional Information
Stay Connected
- Contact the GLP-1 Payment Demonstration team at glp1demo@cms.hhs.gov.
- For questions specific to the BALANCE Model, contact the BALANCE team BALANCEModel@cms.hhs.gov.
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