Medicare GLP-1 Bridge Demonstration - FAQ - 071626

Sep 17, 2026

Uploaded by Aran

Medicare GLP-1 Bridge Demonstration is a short-term CMS program granting eligible Medicare beneficiaries access to select GLP-1 medications for weight loss and weight maintenance from July 1, 2026, through December 31, 2027. The FAQ explains the program’s purpose, clarifies that it is not part of Medicare Part D, lists covered medications and exclusions, and details member eligibility, prescribing and prior authorization steps, expected timelines, and member cost-sharing rules, including copay and deductible handling.

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Overview

Covered Medications

Member Eligibility Criteria

Prescribing and Prior Authorization Process

Member Cost Sharing

Appeals and Denials

Medicare GLP-1 Bridge Demonstration Frequently Asked Questions (FAQ) Overview Q1: What is the Medicare GLP-1 Bridge Demonstration? A1: The Medicare GLP-1 Bridge Demonstration is a short-term CMS program that provides eligible Medicare beneficiaries access to select GLP-1 medications for weight loss and weight maintenance from July 1, 2026, through December 31, 2027. The program operates outside of Medicare Part D coverage and serves as a bridge until CMS determines future coverage options. Q2: Why was this program created? A2: Medicare generally excludes coverage of medications used solely for weight loss under Part D. CMS established the Medicare GLP-1 Bridge Demonstration to provide eligible beneficiaries access to these medications at a reduced cost while gathering additional data on utilization and outcomes. Q3. Is the Medicare GLP-1 Bridge part of Medicare Part D? A3: No. The Medicare GLP-1 Bridge Demonstration is a separate CMS program and is not part of the Medicare Part D benefit. Coverage decisions are made by CMS and its designated program administrator rather than Medicare Part D plans. Covered Medications Q4. Which GLP-1 medications are covered under the program? A4: The following medications may be covered when prescribed for weight loss and weight maintenance: • Wegovy® (all covered injectable and oral formulations) • Foundayo® (orforglipron) • Zepbound® (KwikPen® only) Q5. Are GLP-1 medications prescribed for diabetes or other medical conditions covered through the Bridge program? A5: No. The Bridge program is only for weight loss. Medications prescribed for the below conditions must be processed through the member's regular Medicare Part D plan when applicable: • Type 2 diabetes • To reduce the risk of major adverse cardiovascular (CV) events • Liver disease • Obstructive sleep apnea (OSA) Member Eligibility Criteria In order to determine patient eligibility for Bridge, review the following questions: Q6. Has my patient received a GLP-1 through their Part D plan? A6 . If yes, your patient isn’t eligible for coverage under Medicare GLP-1 Bridge and the provider must submit any request for GLP-1 coverage to the patient’s Part D plan. Q7. Does my patient have type 2 diabetes, moderate-to-severe sleep apnea, or metabolic dysfunction-associated steatohepatitis (MASH)? A7. If yes, your patient isn’t eligible for coverage under Medicare GLP-1 Bridge and the provider must submit any request for GLP-1 coverage to the patient’s Part D plan. Q8. Does my patient meet the Medicare GLP-1 Bridge clinical criteria? A8 . To be eligible, the patient must meet all of the following requirements: • Be at least 18 years of age • Be eligible for enrollment in a Medicare Part D or Medicare Advantage plan for 2026- 2027 • Be prescribed the GLP-1 to reduce excess body weight and maintain weight reduction and not for any other approved indication • Meet the required BMI and clinical criteria at the onset of GLP-1 therapy Eligibility criteria include: BMI ≥ 35 • No additional health conditions required BMI ≥ 30 plus one of the following: • Heart failure with preserved ejection fraction (HFpEF) • Uncontrolled hypertension • Chronic kidney disease (CKD) Stage 3a or greater BMI ≥ 27 plus one of the following: • Prediabetes (A1c 5.7–6.4%) • Prior myocardial infarction (MI) • Prior stroke (CVA) • Symptomatic peripheral artery disease (PAD) Q9: Can patients who already receive GLP-1 coverage through their Medicare Part D plan switch to the Bridge program? A9: No. Patients who are eligible to obtain a GLP-1 medication through Medicare Part D are not eligible to use the Bridge program simply to obtain the lower $50 copay. | Prescribing and Prior Authorization Process
Q10. What steps should providers follow?
A10:
Step 1: Confirm patient eligibility.
Step 2: Send the prescription to the pharmacy with an obesity diagnosis code (the E66 family

FAQs

What is the Medicare GLP-1 Bridge Demonstration?

It is a short-term CMS program that provides eligible Medicare beneficiaries access to select GLP-1 medications for weight loss and weight maintenance from July 1, 2026, through December 31, 2027. It operates outside Medicare Part D coverage.

Which GLP-1 medications are covered and what conditions are excluded?

The program may cover Wegovy, Foundayo (orforglipron), and Zepbound (KwikPen only) when prescribed for weight loss and weight maintenance. GLP-1 use for conditions like type 2 diabetes must go through the member’s regular Medicare Part D plan when applicable.

What copay applies and does it count toward Part D deductibles or out-of-pocket maximums?

Approved beneficiaries pay a flat $50 copay per month for a 28-day or 30-day supply. Payments do not count toward Part D deductibles, True Out-of-Pocket (TrOOP) costs, or annual out-of-pocket maximums because the program operates outside Medicare Part D.

Sep 17, 2026

Uploaded by Aran