Program rules could prove challenging<\/p>\n
To get medications covered under the new program, providers must submit a prior authorization request<\/a> and a prescription for an eligible GLP-1 drug for an approved use. The pharmacist submits the request to the bridge program, which reviews it.<\/p>\n CMS is shooting for a 72-hour turnaround for prior authorization decisions. If it\u2019s approved, the pharmacy can then fill the prescription, so the first time, patients probably won\u2019t be walking out of the drugstore with their first month\u2019s meds.<\/p>\n \u201cObviously, some prior authorization determinations will be made faster. Some of them, we hope, instantaneously. But we are committing to 72-hour turnaround,\u201d a CMS official said during the webinar.<\/p>\n The program also requires providers to attest that a prescribed GLP-1 is to reduce excess weight and maintain weight loss in combination with lifestyle changes, including diet and exercise, CMS says.<\/p>\n Once the first 28- or 30-day prescription is approved through the program, subsequent ones won\u2019t require prior authorization unless the beneficiary switches to a different covered medication, CMS says.<\/p>\n \u201cI imagine that we\u2019ll figure it out. But there\u2019s so many variables.\u201d <\/p>\n \u2014 Anders Gilberg, Medical Group Management Association<\/p>\n \u200b\u201cI imagine that we\u2019ll figure it out,\u201d Gilberg said of medical practice staff who will likely handle some of the program\u2019s administrative requirements for providers. \u201cBut there\u2019s so many variables, like: What kind of plan do you have? What are your diagnoses? There\u2019s just a lot of variables that are going to have to kind of be worked through in each instance of a doctor prescribing one of these for a patient on Medicare.\u201d<\/p>\n The National Community Pharmacists Association, which represents independent pharmacists, is busy making sure its members know about the program because most Medicare benefit changes typically occur in January, says Lisa Schwartz, senior director of professional affairs at the nonprofit trade group.<\/p>\n \u201cFortunately, once the prescriber completes prior authorization for the drug, the program uses routine pharmacy processes,\u201d Schwartz told AARP. \u201cWe would encourage patients to try to have a little extra patience with their provider and the pharmacy the first month or so.\u201d<\/p>\n By providing GLP-1s at a CMS-negotiated price, the bridge program will try to improve enrollees\u2019 health and reduce long-term Medicare spending, a CMS official said.<\/p>\n New GLP-1 program will last 18 months<\/p>\n The program was conceived as a six-month bridge to a proposed Medicare pilot program that was to launch in January 2027. It would have continued the $50 copays for covered GLP-1s through participating Part D plans.<\/p>\n The test program, known as BALANCE<\/a>, was scheduled to run in Part D through 2031 and would have covered all formulations of Mounjaro, Ozempic, Rybelsus and Wegovy, along with the KwikPen formulation of Foundayo and Zepbound.<\/p>\n But in April, CMS indefinitely postponed the test and extended the bridge program by a year. CMS will collect and share GLP-1 use data from the bridge program with Part D insurers and use it to decide later whether the pilot program will happen.<\/p>\n The BALANCE trial program did launch in Medicaid in May 2026 and is scheduled to conclude there at the end of 2031.<\/p>\n The bridge program and BALANCE model are among several Trump administration initiatives designed to expand access and lower the cost of GLP-1 medications.<\/p>\n Join our fight to protect Medicare<\/p>\n AARP is working to keep Medicare strong. Here\u2019s how you can help. \u200b<\/p>\n In November 2025, the administration announced deals with Eli Lilly and Novo Nordisk to provide their GLP-1s at reduced prices. TrumpRx began offering discounted GLP-1 prices earlier this year.<\/p>\n Ozempic, Rybelsus and Wegovy<\/a> were among 15 medications selected for Medicare drug price negotiations<\/a> in 2025 that are expected to provide lower costs in 2027. Medicare spent $15.2 billion on these three GLP-1 medications in 2024.<\/p>\n Research suggests Medicare could spend $65.9 billion for GLP-1s over the next 10 years. However, that higher use could save an estimated $18.2 billion in health care treatment costs, resulting in a net increase of $47.7 billion. \u200b<\/p>\n","protected":false},"excerpt":{"rendered":"Program rules could prove challenging To get medications covered under the new program, providers must submit a prior…\n","protected":false},"author":2,"featured_media":526075,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[33],"tags":[103,61,60,8677,223980,223977,223978,223979,371],"class_list":["post-526074","post","type-post","status-publish","format-standard","has-post-thumbnail","category-medication","tag-health","tag-ie","tag-ireland","tag-medicare","tag-medicare-benefit","tag-medicare-bridge","tag-medicare-glp-1","tag-medicare-weight-loss","tag-medication"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/posts\/526074","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/comments?post=526074"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/posts\/526074\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/media\/526075"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/media?parent=526074"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/categories?post=526074"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/ie\/wp-json\/wp\/v2\/tags?post=526074"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}