The New Medicare GLP-1 Bridge Program: Accessible, Affordable Weight Loss Meds

Do you have overweight patients who need to lose weight to improve their health and activity level or to be eligible for a kidney or kidney-pancreas transplant? Unless you’ve been living under a rock, you’ve probably read or heard about how GLP-1 drugs have been a game-changer to help people who have tried every diet known to man lose weight. One reason why patients say they have been able to lose weight this time is because these drugs stop cravings, or what some call “food noise” that they, but not all people have. Food noise leads many who have lost weight to regain what they lost and sometimes to gain back even more. These drugs can have GI side effects, including:

• Nausea

• Vomiting

• Diarrhea

• Constipation

• Stomach pain

• Pancreatitis risk

However, the main barrier for most people is the drugs’ high cost. For those with Medicare Part D who are medically eligible, a new Medicare GLP-1 Bridge could make it possible for your patients to reach their weight loss goal with a $50 per month copay.

Medicare Part D BALANCE and Medicare GLP-1 Bridge Program Descriptions

By law, Medicare Part D cannot cover drugs for weight loss. However, CMS is working to negotiate prices with drug companies for Medicare’s Part D BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) Model. This model is intended to combine weight loss drugs with evidence-based lifestyle interventions to improve Medicare and Medicaid patients’ health—which may help save Medicare money. The BALANCE Model is optional under Part D and if enough plans participate, will start in 2027 and run through 2031.

Meanwhile, the short-term Medicare GLP-1 Bridge demonstration pilot program will start June 1, 2026 and run through December 2027. A central processor (Humana) will conduct prior authorization, claims, and payment to pharmacies. Eligible Medicare patients will be able to get covered GLP-1 drugs at their local pharmacy for a $50 copay per month. The CMS GLP-1 Bridge program will be the primary payer for these drugs and will not coordinate benefits with other payers. As this program is not under Part D, the $2,100 Part D cap will not apply for them.

Covered Drugs

The GLP-1 Bridge will cover three drugs made by Lilly: all formulations of Foundayo®, Wegovy®, and the Zepbound® Kwik Pen. (Other formulations of Zepbound will not be covered.) There may be updates to the covered drugs.

Eligibility

• Patients must have a standalone Part D plan or a Medicare Advantage plan with drug coverage (MA-PD), be 18 or older, and have or had:

  • BMI ≥ 35 on the date when GLP-1 drugs are or were first taken, or

  • BMI ≥ 30 on the date when GLP-1 drugs are or were first taken and

    1. heart failure with preserved ejection fraction
    2. uncontrolled hypertension (defined as systolic blood pressure above 140 mm Hg or diastolic blood pressure above 90 mm Hg, despite concurrent treatment with two antihypertensive medications)
    3. chronic kidney disease stage 3a or above, or

  • BMI ≥ 27 on the date when GLP-1 drugs are or were first taken and have a diagnosis of one or more of the following

    1. pre-diabetes (as defined by American Diabetes Association guidelines)
    2. previous myocardial infarction
    3. previous stroke
    4. symptomatic peripheral artery disease

• A provider must prescribe the drug and request prior authorization from the central processor (Humana) that will review prior authorization requests, receive claims and pay drugstores.

Those Not Eligible

Patients cannot get Zepbound® or Wegovy® under the GLP-1 Bridge program if they have a condition for which Part D is allowed to cover one or both of these drugs. This includes patients who:

• Are obese and have moderate to severe sleep apnea (for Zepbound®)

• Are at risk of major cardiovascular events (for Wegovy®)

They as well as those with diabetes will get their GLP-1 drugs through Part D as usual. If Part D plans do not have these drugs on their formulary, a patient who has one of these conditions may be able to get the drug through the Part D exception process. Physicians can download and complete the Model Coverage Determination Request Form from that site and send medical justification to the Part D plan to get the drug if approved. CMS will be checking to prevent Part D plans from switching coverage to the Medicare GLP-1 Bridge program from Part D.

Some patients with other insurance cannot qualify for this program. According to a CMS fact sheet, “Beneficiaries enrolled 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 are not eligible to participate, unless also enrolled in a standalone PDP, as applicable.”

Conclusion

In his 2-minute video about the Medicare GLP-1 Bridge pilot program, CMS Administrator, Dr. Oz says the GLP-1 drugs covered under this program can lower a patient’s risk of heart attack, stroke, kidney disease, and joint pain. He says that 80% of Medicare costs are for chronic conditions, so by reducing these risks, this program could save Medicare money. Oz goes on to say that the program is “designed to help more Medicare beneficiaries enjoy better and longer lives” and calls on providers to participate in it.

CMS will be providing more information in June 2026. If your patients meet the eligibility criteria and want to try one of these drugs, let them know about this program that greatly eliminates the financial barrier and help them access it or suggest they reach out to their primary physician for help.