Medicare GLP-1 Bridge Program Eligibility and Costs

The Medicare GLP-1 Bridge is a short-term demonstration run by CMS that gives eligible Medicare Part D beneficiaries access to certain GLP-1 drugs for weight management between July 1, 2026 and December 31, 2027 ^[1][2][3]. Eligible beneficiaries pay a $50 copay for each monthly fill, and the program covers Foundayo, Wegovy (injection and tablets), and Zepbound (KwikPen only) ^[1][3][4][5].

Qualifying takes three things at once: enrollment in an eligible Part D plan type, a prescription solely to reduce excess body weight and maintain weight reduction, and clinical criteria built around BMI thresholds that must have been met when GLP-1 therapy started ^[1][3][5]. People with type 2 diabetes, moderate-to-severe obstructive sleep apnea, or noncirrhotic MASH are excluded, because those indications are already covered under Part D ^[1][3][4][5].

What is the Medicare GLP-1 Bridge?

The Bridge is a demonstration project, not a Medicare Part D plan. CMS states plainly that it “does not constitute a Medicare Part D plan offering prescription drug coverage” ^[1][3]. It operates outside the Part D coverage and payment flow, so Part D sponsors carry no financial risk and do not have to opt in for their enrollees to use it ^[1][2][3][6].

CMS runs the program under Section 402(a)(1)(A) of the Social Security Amendments of 1967, as applied to Part D by section 1860D-42(b) of the Social Security Act ^[2]. The reason a demonstration was needed at all: federal law prohibits Part D plans from covering drugs used for weight loss, and changing that would require Congress to act ^[6][7].

The program was originally scheduled to run only from July through December 2026, but CMS extended it through December 31, 2027 after announcing that the BALANCE Model would not launch in Part D in 2027 ^[6][7]. The extension also lets CMS collect more GLP-1 utilization data to share with Part D plan sponsors ^[1][2][6][7]. In 2026, a single central processor handles prior authorization, claims adjudication, and payment to pharmacies ^[1][2][3]. That processor is Humana, the current administrator of the LI NET program ^[3]. The Bridge is nationwide, available in all states and U.S. territories ^[3][5].

Early uptake has been large. Lilly CEO David Ricks said in September 2026 that about 700,000 seniors had started GLP-1 treatment since coverage launched in July, and that about 70% of them are on Lilly medicines ^[16]. Zepbound appears to be the biggest winner of Medicare coverage so far, and one-third of new patients on oral GLP-1s are taking Foundayo, the Lilly obesity pill that launched in April ^[16]. Ricks also said the Centers for Medicare and Medicaid Services “did a nice job rolling this out,” educating physicians and working with both companies and the insurance system ^[16].

What does the Bridge cost?

Eligible beneficiaries pay a $50 copay, which Medicare.gov lists as a $50 monthly copayment ^[2][5][7]. That $50 is the demonstration copay set by CMS — it is not a cash price, a manufacturer savings-card tier, or a negotiated list price.

Because Bridge drugs are furnished outside the Part D benefit, several normal Part D rules do not apply ^[2]:

Cost rule	How it works under the Bridge
Copay	$50 per monthly fill [2][5][7]
Part D deductible	Does not apply [2]
Counts toward out-of-pocket (TrOOP) costs	No part of the $50 counts [2][7]
Extra Help (low-income subsidy)	Not applied for LIS beneficiaries [2][7]
Part D phase (deductible, initial, catastrophic)	$50 stays the same regardless of phase [7]
Coupons and discount programs	May not be applied to Bridge claims [3]

For comparison, the 2026 out-of-pocket maximum for drugs covered by a Part D plan is $2,100 ^[9]. That cap applies to Part D-covered drugs, not to Bridge fills, since the $50 never counts toward it ^[2][7][9].

The Bridge is the primary payer for covered products and does not coordinate benefits with other payers ^[3].

Which Medicare plans qualify for the Bridge?

Eligibility requires enrollment in a standalone prescription drug plan (PDP) or a Medicare Advantage coordinated care plan with drug coverage (HMO, HMOPOS, and Local and Regional PPO plans, known as MA-PD plans) in calendar year 2026 ^[1][3][5]. Beneficiaries in Special Needs Plans (SNPs), employer/union group waiver plans (EGWPs), and the Limited Income Newly Eligible Transition (LI NET) program are also eligible ^[1][3][5]. Dually eligible beneficiaries in eligible plan types who meet the prior authorization criteria can access the Bridge ^[1][3].

Not eligible, unless also enrolled in a standalone PDP: people in private fee-for-service plans, section 1876 cost contract plans, section 1833 health care prepayment plans, PACE organizations, fallback plans, and religious fraternal benefit plans ^[1][3][4].

For general drug coverage questions, CMS directs beneficiaries to call 1-800-MEDICARE (1-800-633-4227) or their local State Health Insurance Assistance Program (SHIP); TTY users can call 1-877-486-2048 ^[1][2][3].

Why are people with diabetes, sleep apnea, or MASH excluded?

The Bridge was designed for beneficiaries seeking a GLP-1 solely to reduce excess body weight and maintain weight reduction ^[1][3]. Type 2 diabetes, moderate-to-severe obstructive sleep apnea, and noncirrhotic MASH are indications that Part D can already cover, so beneficiaries with those diagnoses are ineligible for the Bridge even if they meet every other criterion ^[1][3][4][5]. Medicare.gov phrases the exclusion as type 2 diabetes, moderate-to-severe sleep apnea, or fatty liver disease ^[5].

Beneficiaries already receiving a GLP-1 covered through their Part D plan are also ineligible, and prescribers must route those coverage requests to the Part D plan ^[4][5].

CMS acknowledges there is overlap between the Bridge criteria and the Part D-covered indication of reducing major adverse cardiovascular events (MACE); the published FAQ text on how that overlap is handled is cut off mid-sentence, so CMS guidance should be checked for the current handling ^[1]. CMS also tells prescribers to use clinical judgment in deciding whether a diagnosis — type 2 diabetes, MASH with F2 to F3 fibrosis, or moderate-to-severe OSA — no longer applies versus being well controlled on treatment ^[1].

What BMI and health criteria apply?

The criteria require age 18 or older and a prescription to reduce excess body weight and maintain weight reduction, combined with ongoing lifestyle modification including structured nutrition and physical activity consistent with the FDA-approved label ^[1][3][4][5]. Then one of three BMI routes must apply:

Route	BMI at start of therapy	Also required
1	BMI of 35 or higher	Nothing else [1][3][4][5]
2	BMI of 30 or higher	Heart failure with preserved ejection fraction, uncontrolled hypertension, or chronic kidney disease stage 3a or above [1][3][4][5]
3	BMI of 27 or higher	Pre-diabetes (per American Diabetes Association guidelines), previous myocardial infarction, previous stroke, or symptomatic peripheral artery disease [1][3][4][5]

Uncontrolled hypertension is defined as systolic blood pressure above 140 mm Hg or diastolic above 90 mm Hg despite concurrent treatment with two antihypertensive medications ^[1][3][4].

The timing rule matters: the criteria are measured at the time GLP-1 therapy was initiated, not at the time of the prior authorization request ^[1][5]. This applies to people who started therapy before enrolling in Part D and/or before the July 1, 2026 launch ^[1]. CMS gives an example: a beneficiary who started GLP-1 therapy in September 2024 with a BMI of 37 and has a BMI of 34 at a July 2026 request — the prescriber attests that the BMI of 35 or higher criterion was met at initiation ^[1].

Meeting the BMI criteria alone is not enough. Plan type, indication, and the prescriber attestation all gate access ^[1][3].

Which drugs and formulations does the Bridge cover?

For the Bridge, an eligible GLP-1 drug is any of the following when used to reduce excess body weight and maintain weight reduction ^[1][3][4][5]:

Product	Covered formulations	Not covered
Foundayo	All formulations (listed as tablets) [1][3][4][5]	—
Wegovy	All formulations, injection and tablets [1][3][4][5]	—
Zepbound	KwikPen only [1][3][4][5]	Single-dose vials and single-dose pens [1][3][4][5]

CMS updated the drug list on April 6, 2026 to add Foundayo following FDA approval and to clarify that only the KwikPen formulation of Zepbound is included ^[1][3]. CMS publishes specific NDC numbers — for example Foundayo 0002-4178-31, Wegovy 0169-4525-14, and Zepbound 0002-3566-11 — and the list may be updated during the demonstration ^[1][3].

Pen needles for the Zepbound KwikPen are not covered. They must not be billed to the Bridge or to the Part D plan, and patients purchase them separately ^[1][3].

How do you sign up and get the drug?

There is no beneficiary enrollment form ^[5]. The process runs through the prescriber and pharmacy:

1. The provider sends a prescription for a covered GLP-1 to the pharmacy and completes a prior authorization when requested ^[5]. The provider must certify the drug is used as part of a lifestyle program focused on diet and exercise ^[5].
2. A Part D denial is not required first. If the prescriber determines the patient might be eligible, they may direct the pharmacist to send the claim straight to the Bridge ^[3].
3. A diagnosis code and a routing annotation on the prescription are recommended to help route it, but are not required for the claim to be processed ^[3].
4. The pharmacy needs the Medicare Beneficiary Identifier (Medicare Number). If the card is unavailable, the pharmacy may ask for the last 4 digits of the Social Security number to look up the Medicare Number via an E1 transaction ^[3][5].
5. Pharmacies do not opt in. Claims go to BIN/PCN 028918 / MEDDGLP1BR per the CMS payer sheet ^[3]. Claims must be electronic via the NCPDP Telecommunication Standard; paper claims and direct member reimbursement are not accepted ^[3].
6. The pharmacy transmits the prior authorization request to the prescriber using its existing processes, with electronic systems supported ^[3].
7. Once approved, the beneficiary receives a letter in the mail confirming coverage under the Bridge ^[5].

Beneficiaries cannot enroll themselves, submit claims directly, or get reimbursed for out-of-pocket purchases — direct member reimbursement is not accepted by the central processor ^[3].

What does the prescriber attest to?

By completing the prior authorization form, the prescriber attests under penalty of perjury that the information is accurate and complete ^[1]. Submitting inaccurate information may expose the prescriber to penalties or prosecution under federal law ^[1]. The Bridge may independently verify submitted information, such as checking Medicare data for whether a patient has type 2 diabetes ^[1]. The Prior Authorization Form and a Prescriber Fact Sheet are posted on the CMS GLP-1 Bridge pages ^[1][2].

How do fills and refills work?

Each fill is a single monthly supply of 28 or 30 days ^[3]. Sixty- and ninety-day fills are not available, and partial fills providing less than a monthly supply are not available either ^[3].

A vacation override is handled at the pharmacy point of sale via submission clarification code 003 ^[3]. There are no manual overrides, and no overrides for lost or stolen medication ^[3].

Prior authorization approvals are valid through December 31, 2027 ^[3][5]. After the first fill is approved, subsequent fills do not need a new prior authorization unless the patient switches from one covered GLP-1 drug to a different one ^[3][5]. Medicare.gov states the approval is valid for refills and dose changes through December 31, 2027, unless the GLP-1 changes ^[5].

Who can you call for help?

Prescribers with questions about a prior authorization request can call the Bridge Call Center at 855-273-0102, Monday through Friday, 8am to 7pm ET ^[1]. Beneficiaries can call 1-800-MEDICARE (1-800-633-4227) with eligibility questions or to check the status of a prior authorization; TTY users can call 1-877-486-2048 ^[2][5]. Medicare.gov also has beneficiary information and an eligibility quiz at Medicare.gov/glp1bridge, on its weight-loss drugs page ^[2][5]. Technical questions can go to glp1demo@cms.hhs.gov, without including personally identifiable or protected health information ^[2][4].

What if you don’t qualify — what are the alternatives?

For beneficiaries with type 2 diabetes, moderate-to-severe sleep apnea, or MASH, the route is the Part D plan, with normal plan coverage and cost sharing ^[1][4][5].

For Part D-covered drugs, the Medicare Prescription Payment Plan lets enrollees spread out-of-pocket costs across the calendar year instead of paying at the pharmacy. It is voluntary, there is no cost to participate, and all plans offer it — but it does not lower drug costs ^[8][9]. It applies only to drugs covered by the Part D plan, not to Bridge drugs ^[2][9]. The 2026 out-of-pocket cap for Part D covered drugs is $2,100 ^[9].

Medicare.gov also points to manufacturer assistance programs, state pharmaceutical assistance programs, comparing mail-order pharmacy costs, and the TrumpRx.gov price comparison site ^[5]. TrumpRx and other discount cards are not creditable coverage, and spending through them does not count toward the Medicare deductible or out-of-pocket maximum ^[5]. Medicare.gov notes that people without Medicare drug coverage may become eligible by enrolling in a drug plan ^[5].

What happens after 2027?

The Bridge is currently set to end December 31, 2027 ^{[1][2][3][6][7]}. What was supposed to follow it — the BALANCE Model (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth), a CMS Innovation Center model originally planned for January 2027 through December 2031 in Medicare — had its Part D portion delayed indefinitely, announced April 21, 2026 and reported in May 2026 ^[6][7]. Whether BALANCE launches in Part D later has not been determined.

The Medicaid side of BALANCE launched May 1, 2026 with rolling implementation through January 1, 2027, and runs through December 31, 2031; the state Medicaid application deadline is July 31, 2026 ^[6]. Separately, the GLP-1 drug semaglutide (Ozempic, Wegovy, Rybelsus) was selected for Medicare drug price negotiation in 2025, with a negotiated price effective in 2027 ^[6]. Only 13 states covered GLP-1s for weight loss in Medicaid as of January 2026, down from 16 in 2025 ^[6].

Sources

1. Centers for Medicare & Medicaid Services. Medicare GLP-1 Bridge: Information for Providers.
2. Centers for Medicare & Medicaid Services. Medicare GLP-1 Bridge.
3. Centers for Medicare & Medicaid Services. Medicare GLP-1 Bridge: Information for Pharmacies.
4. Centers for Medicare & Medicaid Services. Medicare GLP-1 Bridge: Information for Prescribers.
5. Medicare.gov. Weight loss drugs.
6. KFF. What to Know About the BALANCE Model for GLP-1s in Medicare and Medicaid and the Medicare GLP-1 Bridge. May 11, 2026.
7. Medicare Rights Center. GLP-1 Weight-Loss Drug Demonstration Begins July 2026. June 4, 2026.
8. Centers for Medicare & Medicaid Services. Medicare Prescription Payment Plan.
9. Medicare.gov. What’s the Medicare Prescription Payment Plan?
10. Medicare.gov. How much does Medicare drug coverage cost?
11. Medicare.gov. Appeals in a Medicare drug plan.
12. US Food and Drug Administration. Novel Drug Approvals for 2026.
13. Eli Lilly and Company. FDA approves Lilly’s Foundayo (orforglipron), the only GLP-1 pill for weight loss that can be taken any time of day without food or water restrictions. April 1, 2026.
14. Novo Nordisk. FDA approves Novo Nordisk’s new Wegovy HD injection, delivering the highest weight loss to date for a Wegovy injection, adding to its already expansive clinical profile. March 19, 2026.
15. AARP. Medicare $50 GLP-1 Bridge Access and Eligibility.
16. cnbc.com. Eli Lilly CEO David Ricks discusses GLP-1s and Medicare coverage. September 21, 2026.