Medicare’s GLP‑1 Bridge Program

Here’s what that means for you:

• Approved GLP-1 medications for weight loss will be provided through a special program, not your regular Part D drug plan.
• GLP-1 drugs prescribed for other purposes will still be covered by your Part D plan under regular Part D rules and cost-sharing.
• Your Part D plan does not have to sign up for this program for you to get access to the GLP-1 medications.
• A central system run by Medicare will handle approvals, process claims, and pay pharmacies.

What medications are included?

Three specific GLP-1 medications will be covered under the Medicare GLP-1 Bridge program:

• Wegovy (both injections and tablets)
• Zepbound (KwikPen)
• Foundayo

Who is eligible?

To be eligible, you must:

• Be 18 or older
• Need the GLP-1 medication for weight loss and keeping weight off (see below for specific weight and health criteria)
• Have Medicare with prescription drug coverage either through a stand-alone Part D plan or a Medicare Advantage Plan that includes drug coverage
• Have prior authorization
  • Your doctor must write a prescription for one of the approved drugs and submit a request for approval

Additionally, you must meet one of these weight and health criteria to be eligible for the program:

• BMI of 35 or higher
• BMI of 30 or higher and have certain health conditions, such as:
  • Heart failure
  • Uncontrolled hypertension
  • Chronic kidney disease
• BMI of 27 or higher and have other health risks, such as:
  • Pre-diabetes
  • Heart attack
  • Peripheral artery disease

How much will the GLP1- medications cost?

Under the GLP-1 Bridge program you will pay a fixed $50 monthly copay. Keep in mind that the bridge program is separate from your regular Medicare Part D drug coverage:

• Your $50 copay will not count toward your deductible or out-of-pocket limit.
• Cost assistance program like Extra Help cannot be used.
• Your $50 copay stays the same, no matter what stage of Part D coverage you’re in.

Why did Medicare create this program?

Under federal law, Medicare Part D plans cannot cover medications prescribed only for weight loss. GLP-1 drugs, which include medications used to treat type 2 diabetes, obesity, cardiovascular disease, and other conditions, have greatly increased in popularity in recent years due to their demonstrated effectiveness. But because weight loss drugs are not covered by Medicare, people with Medicare have not been able to access these drugs for weight loss unless they pay the full out-of-pocket cost for them. Congress would have to act and change the law to permit or require Medicare Part D plans to cover medications for weight loss, but the Centers for Medicare & Medicaid Services (CMS) can test coverage changes through demonstration programs.

CMS has announced two models to test expanded access to GLP-1 medications for people with Medicare. First, this GLP-1 Bridge Program, and second, the Better Approaches to Lifestyle and Nutrition for Comprehensive Health (BALANCE) model. The BALANCE Model will allow Part D plans to opt into the program to provide coverage for GLP-1 drugs for weight loss for their enrollees. The BALANCE Model has not yet gone into effect.