The Facilities for Medicare & Medicaid Companies (CMS) launched a memo outlining the design of a short-term program that would offer Medicare protection of GLP-1s for weight problems in 2026, forward of a multi-year demonstration program starting in 2027. Medicare is legally prohibited from protecting drugs used for weight reduction, and these demonstration packages are designed to fill that hole.

Beneath the short-term program, referred to as the “Medicare GLP-1 Bridge,” Medicare will cowl GLP-1s authorized for weight discount – Wegovy and Zepbound – for eligible beneficiaries enrolled in Medicare Half D for a $50 copayment. Eligibility is predicated on a BMI of 35 or extra alone, or 27 or extra plus different scientific standards. Though beneficiaries have to be enrolled in Half D to take part, the short-term program exterior of the Half D profit will run from July 1 to December 31, 2026. As a substitute, suppliers will submit GLP-1 prescriptions and prior authorization requests to a central processor managed by CMS.

CMS’s efforts to supply Medicare protection of GLP-1s for weight problems may present substantial advantages to thousands and thousands of Medicare beneficiaries given the excessive demand for these medicine. The variety of beneficiaries eligible for the Medicare GLP-1 Bridge is unknown, however a earlier KFF evaluation estimated that just about 14 million Medicare beneficiaries have been recognized as chubby or overweight in 2020 (BMI of 25-29.9 and 30 or extra, respectively), though making use of the particular standards that decide eligibility for the Medicare GLP-1 Bridge would cut back that quantity.

Nonetheless, there are potential drawbacks to the short-term program. As a result of it falls exterior the Half D profit, the $50 copayment doesn’t rely towards the Half D deductible or the $2,100 out-of-pocket spending restrict. Half D contributors who take a GLP-1 for sort 2 diabetes, sleep apnea, or different Medicare coated makes use of will proceed to entry the drug by way of their Half D plan and pay their plan’s cost-sharing requirement, even whether it is greater than the $50 copayment for GLP-1s for weight problems underneath the Medicare GLP-1 Bridge. And low-income Medicare beneficiaries who qualify for decrease value sharing by way of the Half D low-income subsidy can not use these subsidies for GLP-1 prescriptions crammed underneath the short-term program. For people with low and modest incomes, the $50 copayment could also be a barrier to participation.

One other potential subject is that beneficiaries taking part within the short-term program have to be enrolled in a Half D plan that participates within the longer-term demonstration, referred to as the BALANCE mannequin, to proceed accessing Medicare protection of GLP-1s for weight problems starting in 2027. CMS is dedicated to strong Half D plan participation within the BALANCE mannequin, which is voluntary for plans, however that is nonetheless unsure. Transitioning Medicare protection of GLP-1s for weight problems from the necessary Medicare GLP-1 Bridge to the voluntary BALANCE mannequin raises the likelihood that beneficiaries with protection underneath the short-term program might have to modify to Half D plans in the course of the 2027 open enrollment interval, probably impacting prices and protection for different drugs they take.