How will Medicare help people afford GLP-1s?
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There have been many headlines in the last week about $50 weight-loss drugs for Medicare beneficiaries and the Medicare GLP-1 Bridge. Anyone who is trying to lose weight wants to know about the Medicare GLP-1 Bridge.
Let’s start with a little history. In December 2025, the Centers for Medicare & Medicaid Services introduced the BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) Model. Part D law forbids plans from covering weight-loss drugs. This five-year demonstration would waive the coverage exclusion for these drugs to increase access to GLP-1 medications. This would help Medicare and Medicaid beneficiaries lose weight and improve their health.
Until fully implemented in 2027, CMS set up the Bridge to provide GLP-1 drugs for qualified individuals until the BALANCE Model was up and running. However, on April 21, CMS announced it would delay the BALANCE Model for Medicare beneficiaries because it had not secured sufficient commitments from Part D insurers. (CMS will still accept applications from state Medicaid agencies.)
Here are some important points to know.
What is the Bridge program?
Under this short-term demonstration, eligible Part D beneficiaries will have access to selected GLP-1 drugs for a $50 copayment. As initially designed, the Bridge would end in December 2026. However, with the Medicare portion of the BALANCE Model on hold, CMS extended the Bridge until December 31, 2027.
When will the $50 GLP-1 drugs be available?
Qualified beneficiaries can get these $50 drugs beginning July 1, 2026.
What is a GLP-1 drug?
A glucagon-like peptide-1 drug mimics hormones in the body that boost insulin release, reduce glucagon and slow stomach emptying. This class of medications treats type 2 diabetes and obesity.
Which GLP-1 drugs are included in this demonstration?
There are three drugs: Wegovy, Zepbound and Foundayo. All formulations of Wegovy and Foundayo are approved but only the Zepbound KwikPen will be available.
An important note: Zepbound has been approved for sleep apnea and Wegovy for cardiovascular risk, with weight loss as a side benefit. However, the Bridge program will pay for these drugs only when used specifically for weight loss.
Can any Medicare beneficiary participate?
They can if enrolled in a standalone Part D prescription drug plan, Medicare Advantage plan or any other plan that includes Part D drug coverage. Then they must meet the clinical criteria and commit to lifestyle modifications.
What are the clinical eligibility criteria?
The participant must be at least 18 years old and:
- Have a BMI of 35 or greater, or
- Have a BMI of 30 or greater with a diagnosis of diastolic heart failure, uncontrolled hypertension or chronic kidney disease Stage 3a or higher, or
- Have a BMI of 27 or greater with pre-diabetes, previous myocardial infarction or stroke, or symptomatic peripheral artery disease.
These criteria are very specific so not everyone who needs to lose weight will qualify for the Bridge program. However, there will be many who do. Almost 30% of adults age 65 and older have a BMI of 30 or higher.
What is BMI?
Body mass index is a screening tool that uses height and weight to estimate body fat. The BMIs of 27 and higher in the demonstration connect to the categories of “overweight” and “obesity.”
To give the BMI some perspective, a person 6 feet tall, 258 pounds, has a BMI of 35 and the BMI for someone 5 feet tall, 138 pounds is 27. (Calculate your BMI here.)
What is the physician’s involvement in this program?
Prescribing physicians do not need to be enrolled in Medicare; however, they cannot be on the preclusion list. They must attest that the beneficiary met the clinical criteria at the time GLP-1 therapy was initiated and is participating in a lifestyle modification program. (Watch for more details on this.) Physicians must also submit a prescription and prior authorization request to the central processor when required. (See next question.)
How is a prescription handled?
CMS has designated Humana as the central processor to handle prior authorizations, claims and payment to pharmacies.
The Medicare GLP-1 Bridge will be the primary payer for covered medications. Because this program is outside the Part D operation, it will not coordinate with other payers.
What about pharmacies and the Bridge?
One memo says CMS will provide more information on pharmacy participation and claims processing in the coming months. (The July 1 deadline is only six weeks away.) CMS did write that pharmacies do not need to opt in to participate and, because the Bridge is outside of Part D, network pharmacies won’t be an issue. I could not find any mention of mail order pharmacies so it may be best to start with retail pharmacies.
What does a beneficiary need to know?
Just as with pharmacies, more information will be coming. The eligibility criteria top the list and then these points are important.
- There will be a $50 copayment when getting the drug from a pharmacy.
- These copayments will not apply to the Part D deductible or the out-of-pocket cap ($2,100 this year).
- Low-income subsidies will not apply.
- Participants will need to meet whatever other requirements CMS puts in place, such as participating in lifestyle modifications.
How does an eligible beneficiary get started?
- Meet with a physician to verify BMI and diagnoses met the criteria at the time GLP-1 therapy was initiated (not when participation in the Bridge began).
- Ask the physician to submit a prescription and necessary prior authorization to the central processor, Humana, and not the Part D plan.
- Verify that the pharmacy knows about this program and will submit the claim to Humana.
- Participate in the lifestyle modifications.
- Watch for more details coming about important points in this program.
Is there anything else?
A couple of points highlight the role of the beneficiary in knowing about this program and being proactive.
- This may be an opportunity to get a GLP-1 drug that a Part D plan does not cover. Checking five ZIP codes in the Medicare Plan Finder, I did not find one Part D or Medicare Advantage plan that covers Wegovy or Zepbound. Because Foundayo has been approved only for weight loss, it is not a drug Part D plans could cover.
- If a Part D plan sponsor receives a prescription request for one of the three GLP-1 drugs it does not cover, CMS strongly encourages the sponsor to inform the prescribing physician to contact the central processor. There’s a chance that may not happen so the onus shifts to the beneficiary to take charge. Confirm that both the physician and pharmacist know about participation in the GLP-1 Medicare Bridge.
These are crazy times for Medicare beneficiaries. To deal with the rapid-fire changes, they must take steps to ensure they’re included. If you think you’re eligible for this program, ask a few questions and keep up with developments. This could change your life.
