Newsletter

HOW MEDICARE BENEFICIARIES WILL RECEIVE GLP 1 MEDICATIONS UNDER THE BALANCE BRIDGE DEMONSTRATION (STARTING JULY 1, 2026)

This article is an update to the special announcement newsletter we sent out in June, which indicated we would be forwarding instructions for submitting prescriptions and for beneficiaries obtaining covered medications beginning July 1, 2026.

Medicare is launching the GLP‑1 BALANCE Bridge Demonstration, a temporary program that allows eligible Medicare beneficiaries who are enrolled in a Part D drug plan (either Medicare Advantage Prescription Drug Plan or stand-alone Part D coverage) to receive one of these weight loss medications--Foundayo (orforgliprom) (all formulations), Wegovy (semaglutide) (all formulations), and Zepbound (tirzepatide) (Kwikpen only)-- for a flat $50 per month, regardless of dose. The program uses a single national processor to handle all prior authorizations and pharmacy claims and follows a different procedure than is followed for drugs covered under Part D of Medicare.

This document was published very recently by Medicare (CMS) and will be updated regularly. Because this program is structured differently from anything that has previously existed in Medicare, we expect significant confusion among prescribers, pharmacies, and beneficiaries.

Doctors and pharmacies may not have received this information, so we suggest making a copy of the document and presenting it to both your pharmacy and doctor. The program is beginning to receive significant media attention and there is much incorrect information being circulated.

STEP-BY-STEP INSTRUCTIONS FOR OBTAINING MEDICATIONS UNDER THIS PROGRAM:

For the patient/beneficiary:

1. Talk to your doctor about whether a GLP-1 drug is right for you and whether you meet the BMI/clinical criteria (BMI ≥35 alone; BMI ≥30 with certain conditions like heart failure, uncontrolled hypertension, or CKD stage 3a+; or BMI ≥27 with prediabetes, prior heart attack/stroke, or PAD).

2. Doctor sends the prescription to your pharmacy for one of the covered drugs (Wegovy, Zepbound KwikPen, or Foundayo).

3. Pharmacy may ask for your Medicare ID (or last 4 digits of your SSN if you don't have your card, so they can look up your number).

What happens at the pharmacy (the claims mechanics)

4. The pharmacy electronically submits the claim to the Bridge's central processor (not your regular Part D plan), using the NCPDP Telecommunication Standard, with a Bridge-specific Bank Identification Number and Processor Control Number (028918 MEDDGLP1BR).

5. Even for an eligible patient, the Bridge will initially deny the claim — but this denial automatically triggers a prior authorization (PA) requirement, and the pharmacy sends that PA request form to your prescriber, typically within 24–72 hours.

Prior authorization (prescriber's role)

6. Your prescriber confirms you're in an eligible Part D plan type, haven't already gotten a GLP-1 through Part D, and don't have type 2 diabetes, moderate-to-severe sleep apnea, or MASH (Metabolic Dysfunction-Associated SteatoHepatitis) — then confirms you meet the BMI/diagnosis criteria. Please see this guide for doctors and prescribers that was published in Medicare Tools on June 25.

7. The prescriber includes an obesity diagnosis code from the E66 family and a note like "SEND TO BRIDGE FOR WEIGHT MANAGEMENT" on the prescription so it routes correctly — otherwise the claim could default to your Part D plan and trigger a different process.

8. The prescriber completes and submits the PA form, attesting under penalty of perjury to your BMI/clinical criteria at the time therapy was initiated (even if your BMI has since changed). [Note: the PA form for the Bridge program is available at https://www.cms.gov/glp-1-bridge.pdf and includes clinical criteria, required documentation, and prescriber attestations.]

9. CMS's central processor reviews and approves/denies the PA.

After approval

10. Once approved, you pick up your first fill for a $50 copay (only 28- or 30-day fills are covered).

11. Subsequent refills don't need a new PA — unless you switch to a different covered GLP-1 drug, which requires a fresh prior authorization.

A few important caveats:

• Paper claims and direct member reimbursements are not accepted — everything must go through the electronic central processor.

• Coupons and manufacturer discount programs can't be applied to Bridge claims.

• Pharmacies don't need to opt in to participate.

• Patients themselves can't submit the PA paperwork — it must come from the prescriber.

For program questions, contact CMS at glp1demo@cms.hhs.gov or visit the CMS Medicare GLP-1 Bridge webpage. Please call us at 786-970-0740 (Cell) or 561-734-3884 / 877-734-3884 (TTY: 711) with any questions about this program or for help determining whether you may qualify.

MEDICARE’S NEW BALANCE GLP-1 INITIATIVE BEGINS JULY 1

Medical billing mistakes are far more common than most people realize — and Medicare beneficiaries are especially vulnerable. BarleyMedical.com is a free online tool created specifically for Medicare beneficiaries to help them review their medical bills, identify possible errors, and spot signs of fraud before paying a dime.

 Visit: https://www.barleymedical.com

What Barley Helps Medicare Beneficiaries Do

Barley is designed with Medicare users in mind. It helps people:

• Review Medicare-related medical bills line‑by‑line
• Identify potential billing errors, such as duplicate charges or services not received
• Spot signs of Medicare fraud or upcoding
• Understand whether charges look appropriate for Medicare
• Learn what steps to take if something appears incorrect

Barley does not replace the Medicare Summary Notice (MSN) or Explanation of Benefits (EOB). Instead, it gives beneficiaries a clearer, easier way to understand their bills before contacting a provider or Medicare.

What It Costs

BarleyMedical.com is free for Medicare beneficiaries. There are no subscriptions, upgrades, or hidden fees.

Why This Matters For Medicare Users

Medicare beneficiaries often receive multiple bills from multiple providers — and errors can slip through easily. Barley helps people:

• Avoid paying for services they didn’t receive
• Catch billing mistakes early
• Reduce exposure to Medicare fraud
• Feel more confident before paying a medical bill

For anyone on Medicare, Barley provides an extra layer of protection and clarity.

MEDICARE STAR RATINGS IN 2027: WHAT TO EXPECT

About Paul Cholak

Paul is a licensed, independent health and life insurance agent and has over forty years of benefits experience and specializes in helping Medicare beneficiaries obtain health insurance. However, he offers a complete array of life and health insurance products to individuals of all ages.

He guides Medicare beneficiaries through the steps of getting insurance and is available to help clients both BEFORE and AFTER they've made their purchase decision.

Disclaimer for Part C and D plans: "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE (TTY: 1-877-2048) to get information on all your options."

Contact Us

Local: 561-734-3884 (TTY: 711)

Toll-free: 877-734-3884 (TTY:711)