CMS is rolling out the Medicare GLP-1 Bridge program — a demonstration designed to give eligible Medicare Part D beneficiaries access to certain GLP-1s at a fixed monthly cost — July 1.
CMS officials, including CMS Administrator Mehmet Oz, MD, broke down eligibility, pricing and prior authorization during a June press call.
The program runs from July 1, 2026, through Dec. 31, 2027. Throughout the 18 months, CMS aims to gather data on how expanded GLP-1 access affects health outcomes, utilization and program operations.
Manufacturers are providing GLP-1s at a net price of $245 per month. Medicare beneficiaries will shoulder $50, while CMS will cover $195. Foundayo, Wegovy and Zepbound are available through the program.
The Bridge program bypasses Part D sponsors, whereas the voluntary “Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth” model pilot for Medicare Part D required sponsors to sign on. After the sponsor application window closed, BALANCE was indefinitely put on hold for Part D, and the Bridge program was extended.
A CMS website said the agency plans to share data with Part D sponsors that could be interested in possible BALANCE participation, and CMS officials said they anticipate releasing more information to sponsors in the coming weeks. Despite the Bridge program operating through a different pathway than Part D, Humana will serve as the central processor. Coupons and discounts will not apply to the Bridge program, according to the website. CMS expects no premium impact, as well.
The program lays out strict clinical criteria — including a minimum body mass index, depending on comorbidities — focused on losing weight and maintaining the loss, and is very careful to not duplicate GLP-1 coverage. Beneficiaries who can already access a GLP-1 through Part D, such as for Type 2 diabetes, are not eligible for the program. While providers can resubmit eligibility forms as many times as they would like, there is no formal appeals process within the Bridge program, a CMS official said.
Still, many questions remain. Here are the big ones:
1. How many people will enroll, and what could savings look like? CMS could not confirm cost or enrollment projections on the call. KFF recently estimated 3.8 million people could have been eligible in 2023 for the Bridge program, building on CMS Medicare Director Chris Klomp’s expectation that participation will be in the “single-digit millions” at first. Marketing has been limited so far, and CMS plans to increase outreach after the start date as beneficiaries can take action. Leaders also said they have private sector estimates on possible cost savings but want to use the demonstration to get more concrete numbers.
2. What comes after the 18-month demonstration ends? CMS declined to provide an update on BALANCE’s potential and said it is too early to determine the Bridge program’s future, as well. Dr. Oz said the team needs to review Bridge’s data and is “hoping that with 18 months of information we will be encouraged enough to let it keep going, but also there are a lot of new medications coming out [and] there are other negotiations going on with these companies.”
3. Will Part D sponsors engage more in the future? A CMS official said Part D sponsors are interested in aggregate and beneficiary-level data, and the agency anticipates releasing more information to sponsors in the coming weeks. Still, the data-sharing cadence and next steps for plans are unclear.
4. Will Congress work toward permanent Medicare coverage of weight-loss drugs? Dr. Oz said it’s up to Congress to debate possible legislation, but new laws are not necessary at the moment, given the agency’s ability to operate Bridge.
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