While the Medicare GLP-1 Bridge program is still expected to go live in July, it is being extended from a six-month program to 18 months, ending Dec. 31, 2027. This is to regroup after indications that the CMS Innovation Center BALANCE Model was a challenging program for Part D plans to assess and submit an application by the April 20 deadline. State Medicaid agencies can still apply and can offer coverage for the weight loss indication as soon as May 1, 2026.
The main takeaway for pharmacies is that for 18 months starting July 1, 2026, your patients with a Medicare prescription drug benefit (Medicare Advantage or stand-alone PDP) who meet the GLP-1 Bridge clinical criteria for weight loss may have coverage, with a $50 cost share for specified products. The product list is currently Foundayo®, Wegovy® (injection and tablets), and Zepbound® (KwikPen®). Pharmacies will be reimbursed by CMS’ Bridge central processor at the wholesale acquisition cost of a drug, less the beneficiary copay, plus a dispensing fee and, as applicable, sales tax.
NCPA is in regular contact with CMS and an NCPDP task group of pharmacies, PBMs, and technology partners to develop the workflows, claim processes, and FAQ for the GLP-1 Bridge. You should expect to obtain an ICD-10 code (via the e-prescription or contacting the prescriber) to submit on the claim to CMS’ Bridge central processor. If you are interested in joining this NCPDP task group that meets on Tuesdays at 2 p.m. ET, email lschwartz@ncpa.org.
