Medicare GLP-1 Bridge guidance sets $50 copay and prior authorization rules for Wegovy and Zepbound

The agency that administers Medicare has released written answers to common questions about its temporary GLP-1 obesity coverage program, setting the copay at a flat $50 a month and laying out the paperwork and clinical tests patients must clear before the program opens on July 1 ^[1].

Three products will be offered for weight management: all formulations of Wegovy (semaglutide) and Foundayo (orforglipron), and Zepbound (tirzepatide) in its KwikPen version ^[1]. Enrollees in a Part D plan pay $50 each month ^[1]. Those payments will not be credited toward the annual ceiling on what Part D members spend out of their own pockets, according to the guidance ^[1].

Who can get in

Doctors must file a prior authorization request stating the medication is prescribed to reduce excess body weight and to keep the weight off, and the request has to show the patient fits one of three groups ^[1]. Patients also must be at least 18 and enrolled in Part D ^[1].

The groups rest on body mass index and other diagnoses. A BMI of 35 or higher qualifies on its own. So does a BMI of 30 or higher combined with heart failure with preserved ejection fraction, uncontrolled hypertension, or chronic kidney disease at stage 3a or beyond. A BMI of 27 or higher works if the patient also has prediabetes, has had a heart attack or a stroke, or has symptomatic peripheral artery disease ^[1].

The program is a nationwide demonstration run under Section 402 authority and kept apart from the standard drug benefit. Part D plans do not need to sign up for their members to take part, and they carry no financial risk for the costs ^[1].

Why it matters for patients

Federal law has long blocked Medicare from paying for medicines used purely for weight loss, so the drug benefit covers GLP-1s today only when they are prescribed for another accepted use, such as type 2 diabetes, lowering cardiovascular risk or sleep apnea ^[1]. The demonstration carves out a short-term exception, giving some beneficiaries a route to treatment for obesity without shouldering the full cash price.

Affordability remains the main obstacle for this drug class. In KFF polling, about 56% of people taking GLP-1s described them as hard to pay for, and one in four called it "very difficult" ^[1].

Two features of the new guidance stand out. First, the BMI cutoffs and listed conditions draw a hard line: people who do not fit one of the three groups cannot use the program ^[1]. Second, because the monthly $50 is not counted toward the out-of-pocket maximum, those payments will not bring anyone closer to the threshold where Part D's catastrophic protections begin ^[1]. How the charge interacts with employer or retiree drug coverage has not been disclosed ^[1].

Geography matters too. States may decide for themselves whether to cover these medicines for weight loss, and 13 states did so as of January 2026, fewer than the 16 that covered them in 2025 ^[1].

Spending on the drug class in public programs is already substantial. Medicare recorded 21.8 million GLP-1 claims and $27.5 billion in gross spending in 2024, while Medicaid logged 8.4 million prescriptions and $8.6 billion, both figures calculated before rebates ^[1].

What happens next

July 1, 2026: coverage begins for Part D members who meet the criteria. The demonstration was originally set to end in December 2026 and has been extended through December 31, 2027 ^[1].

May 2026 through December 2031: a separate model called BALANCE is scheduled to widen obesity coverage in Medicaid, with states applying on a rolling basis ^[1].

Medicare's version of BALANCE, once slated to start in January 2027, has been delayed indefinitely ^[1].

2027: A negotiated Medicare price for semaglutide — sold as Ozempic, Wegovy and Rybelsus — is due to take effect after the drug was chosen for negotiation in 2025 ^[1].