When CMS announced the Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) Model to cover certain GLP-1 drugs for weight loss to start in 2027, it mentioned a second, short-term demonstration project to give Part D enrollees coverage as soon as July 2026. A new Frequently Asked Questions document provides some details on this Medicare GLP-1 Bridge while acknowledging that many questions don't have answers yet. NCPA has been advocating to CMS for fair and transparent pharmacy payment for these drugs, as we know that current Medicare Part D PBM payments for these drugs are leaving pharmacies underwater.
It may be encouraging for pharmacy owners to see that reimbursement will be no less than WAC plus (an unspecified) dispensing fee and, as applicable, sales tax. Prescribers need to complete prior authorization to ensure patients meet coverage criteria.
