CMS Announces Changes to Medicare Coverage of GLP-1 Medications for 2027

Following previous announcements that Medicare would cover GLP-1 medications through Part D plan sponsors in 2027 under the Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth – or BALANCE – Model, the Centers for Medicare and Medicaid Services (CMS) recently provided updated guidance indicating that the BALANCE model would not launch for Medicare in 2027. Rather, CMS is extending the Medicare GLP-1 Bridge Model through December 31, 2027.

As a reminder, the Bridge Model is a short-term demonstration that CMS is operating to provide eligible Medicare Part D beneficiaries with access to certain specified GLP-1 drugs starting in July 2026. While the Bridge Model was originally scheduled to end December 31, 2026 – to be replaced by BALANCE on January 1, 2027 – CMS extended the Bridge Model to allow for ongoing coverage of GLP-1 medications given the delay of the BALANCE model.

The extension of the Bridge Model will enable eligible Part D beneficiaries across the country to access covered GLP-1 medications through December 2027, regardless of their Part D plan sponsors’ participation decisions. The Medicare program will operate the program outside of the Part D benefit through a contract with Humana, which will serve as the central processor for the Bridge Model. Humana will be responsible for managing prior authorization, claims adjudication, and payment to pharmacies.

Part D beneficiaries must be enrolled in a standalone prescription drug plan (PDP) or a Medicare Advantage (MA) coordinated care plan that offers prescription drug coverage (MA-PD plan). Beneficiaries in certain other arrangements, however, are not eligible to participate unless they are also enrolled in a standalone PDP, as applicable. (See here for more information.)

Beneficiaries will also be required to meet clinical criteria, as determined based on submission of a prior authorization request to the central processor. Additional information on the prior authorization process is expected in June.

Eligible beneficiaries will be able to access prescriptions with a $50 copay under the Bridge Model, and because the model will operate outside of the Part D benefit, the $50 copay will remain the same, regardless of the phase of the Part D benefit an eligible beneficiary is in. At the same time, beneficiary and Medicare spending on GLP-1s will not count towards the eligible beneficiary’s gross covered prescription drug costs or true out-of-pocket costs. (See here for more information on interaction with Part D plan drug coverage.)

CMS has posted Frequently Asked Questions (FAQs) on the Bridge Model website, and additional updates are expected prior to the model’s July launch.

Notably, the BALANCE Model also includes a Medicaid component, under which State Medicaid agencies can apply to participate through January 1, 2027. Participating state Medicaid programs will be able to benefit from CMS’ drug pricing and coverage negotiations with manufacturers of GLP-1 medications to provide the medications to eligible Medicaid beneficiaries. CMS’ announced changes to Medicare coverage of GLP-1 medications are not expected to affect Medicaid coverage of the medications under the BALANCE model. OMA recently sent letters to all 37 state governors of states that do not currently cover obesity medications, including GLP-1s, encouraging them to apply for the BALANCE Model. Members of the OMA can access copies of these letters by logging in to the Connect platform and searching the Advocacy Resources.