CMS tells Part D plans the Medicare GLP-1 Bridge sits outside their benefit

CMS has published implementation guidance for Medicare Part D plans taking part in the Medicare GLP-1 Bridge, a short-term demonstration that gives eligible Part D beneficiaries access to certain GLP-1 drugs for weight management. The program runs from July 1, 2026 through December 31, 2027, and CMS says it operates outside the Part D benefit's coverage and payment flow ^[1].

Because of that structure, Part D sponsors do not carry risk for eligible GLP-1 drugs furnished under the Bridge, and sponsors do not have to opt in for beneficiaries to get these drugs starting July 1, 2026 ^[1]. In 2026, CMS will use a single central processor — Humana, the current administrator of the Limited Income Newly Eligible Transition (LI NET) program — to manage prior authorization, claims adjudication and payment to pharmacies ^[1]. The agency cites Section 402(a)(1)(A) of the Social Security Amendments of 1967, made applicable to Part D by the Social Security Act, as its authority ^[1].

COVERED PRODUCTS

The Bridge covers Foundayo (orforglipron), Wegovy (semaglutide, injection and tablets), and the Zepbound (tirzepatide) KwikPen ^[1]. The single-dose vial and single-dose pen forms of Zepbound are not included ^[1]. CMS updated the list on April 6, 2026 to add Foundayo after FDA approval and to clarify that only the KwikPen formulation of Zepbound is included ^[1]. All formulations of Foundayo and Wegovy are available, and CMS lists specific National Drug Codes for each product; the list may be updated during the program ^[1].

WHAT IT COSTS

Participating manufacturers provide eligible GLP-1 drugs at a net price of $245 per monthly supply, and eligible beneficiaries pay a $50 copay ^[1]. Neither the $245 nor the $50 copay counts toward a beneficiary's gross covered prescription drug costs or true out-of-pocket costs under their Part D plan ^[1]. The $50 copay stays the same no matter which phase of the Part D benefit the person is in when they fill the prescription, and low-income cost-sharing subsidies do not apply to any portion of it ^[1].

The Bridge is the primary payer and does not coordinate benefits with other payers, and coupons and discount programs may not be applied to Bridge claims ^[1]. Claims are processed electronically under the NCPDP Telecommunication Standard; paper claims and direct member reimbursements are not accepted ^[1].

WHO QUALIFIES

A provider must submit a prior authorization attesting that the beneficiary is at least 18, is prescribed the drug to reduce excess body weight and maintain weight reduction alongside ongoing lifestyle changes, and meets one of three BMI paths: a BMI of 35 or higher; a BMI of 30 or higher with heart failure with preserved ejection fraction, uncontrolled hypertension (systolic pressure above 140 mm Hg or diastolic above 90 mm Hg despite two antihypertensive medications), or chronic kidney disease stage 3a or above; or a BMI of 27 or higher with pre-diabetes, a previous heart attack, a previous stroke, or symptomatic peripheral artery disease ^[1].

People with type 2 diabetes, moderate to severe obstructive sleep apnea, or noncirrhotic MASH with moderate to advanced liver scarring are not eligible for the Bridge, even if they otherwise meet its clinical criteria, because those uses can be covered under Part D ^[1]. CMS says that holds even if a person's Part D plan does not cover a GLP-1 for that condition ^[1]. Anyone who filled a GLP-1 through a Part D plan in 2026 is also ineligible, including people whose plan covered weight management as supplemental coverage through an Employer Group Waiver Plan ^[1]. CMS reviews its own data for that check across Zepbound, Mounjaro, Foundayo, Rybelsus, Ozempic, Wegovy, Saxenda, Victoza and Trulicity; pharmacies receive a notification when someone is ineligible, and beneficiaries can call 1-800-MEDICARE ^[1].

CMS encourages plans that get a prior authorization request for a Bridge-eligible drug to send the provider a message directing them to the central processor, and says it will work with the National Council for Prescription Drug Programs on standard messaging ^[1]. The Bridge does not change beneficiary appeal rights, including exception requests ^[1]. CMS says it will monitor formularies and utilization management to make sure plans do not shift coverage decisions onto the Bridge ^[1].

Why it matters for patients

For Medicare Part D beneficiaries who want a GLP-1 mainly for weight management, the Bridge may be the route to coverage when their plan does not cover that use ^[1]. The fixed $50 copay does not move with the Part D deductible or benefit phases, but it also does not build toward the true out-of-pocket limit that caps a person's yearly Part D spending, and low-income cost-sharing help does not apply to it ^[1]. Coupons and discounts cannot be added to Bridge claims ^[1].

A prescription written for a use Part D can cover — type 2 diabetes, moderate to severe obstructive sleep apnea, or MASH with moderate to advanced fibrosis — keeps a beneficiary out of the Bridge entirely, so those patients stay with their Part D plan ^[1]. Prior GLP-1 use through a Part D plan in 2026 also blocks Bridge access that year, which could surprise people who got a GLP-1 through a plan's supplemental weight-management coverage ^[1].

What happens next

• July 1, 2026: the Bridge begins, with the central processor handling prior authorization, claims and pharmacy payment ^[1].
• December 31, 2027: the Bridge is scheduled to end ^[1].
• CMS has not yet determined the lookback period it will use in 2027 to check prior Part D GLP-1 use ^[1].
• CMS anticipates issuing NCPDP guidance, expected to include standard messaging for plans to use with providers; no date is given ^[1].

CMS says the Bridge was extended through 2027 because the BALANCE Model is not launching that year, and that the extra run time will let it collect more GLP-1 utilization data to share with Part D plan sponsors ahead of a potential BALANCE launch in Part D ^[1].