A Historic Shift in Medicare Drug Coverage

For decades, Medicare was explicitly prohibited from covering prescription medications prescribed solely for weight loss. That changes on July 1, 2026, when the Medicare GLP-1 Bridge launches — a short-term demonstration program that will provide eligible Medicare Part D beneficiaries with access to specific GLP-1 medications at a $50 monthly copay.

The Bridge was announced by CMS on December 23, 2025, as a precursor to the broader BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) Model. It will run from July 1, 2026 through December 31, 2027.

Which Medications Are Covered?

The Bridge covers specific FDA-approved brand-name GLP-1 products prescribed for weight management. The eligible medications include all Wegovy formulations (injection, oral tablet, and the 7.2mg HD injection), all Foundayo (orforglipron) formulations, and Zepbound KwikPen (tirzepatide). Compounded GLP-1 medications are not covered under the Bridge. Medications prescribed for diabetes (Ozempic, Mounjaro) continue to be covered under standard Medicare Part D, not the Bridge.

Who Qualifies?

Eligibility is based on three tiers — you only need to meet one. The first tier requires a BMI of 35 or higher at the time of initiating GLP-1 therapy. The second tier requires a BMI of 30 or higher plus at least one of the following: heart failure with preserved ejection fraction (HFpEF), uncontrolled hypertension despite treatment with two or more antihypertensive medications, or chronic kidney disease stage 3a or higher. The third tier requires a BMI of 27 or higher with either prediabetes (as defined by American Diabetes Association guidelines), a previous myocardial infarction (heart attack), a previous stroke, or symptomatic peripheral artery disease.

Important timing detail: BMI is measured at the time you initiated GLP-1 therapy, not your current BMI. If you started a GLP-1 at a BMI of 37 and have since lost weight to a BMI of 34, your provider should attest to the BMI at initiation. This means patients who are already on GLP-1 medications and have lost weight can still qualify.

Which Medicare Plans Are Eligible?

You must be enrolled in a standalone Prescription Drug Plan (PDP) or a Medicare Advantage plan with prescription drug coverage (MA-PD) in 2026. This includes beneficiaries in Special Needs Plans (SNPs), Employer/Union Group Waiver Plans (EGWPs), and the Limited Income Newly Eligible Transition (LI NET) program.

Plans that are not eligible include private fee-for-service plans (unless also enrolled in a standalone PDP), section 1876 cost contract plans, PACE organizations, fallback plans, and religious fraternal benefit plans. Part D sponsors do not need to opt in — the Bridge operates outside the standard Part D benefit.

What Does It Cost?

The beneficiary copay is a flat $50 per month. CMS covers the remaining balance. This copay does not count toward your True Out-of-Pocket (TrOOP) costs under Part D. There are no deductible requirements specific to the Bridge — the $50 copay is the only direct cost to the patient.

How to Enroll

Enrollment happens through your prescribing provider, not through the Medicare plan itself. Your healthcare provider must submit a prior authorization request to CMS's central processor (not to your Part D plan), along with a prescription for one of the eligible GLP-1 medications and attestation that you meet one of the three eligibility tiers.

CMS will process the PA and, if approved, the medication can be filled at participating pharmacies. Pharmacies are reimbursed at the wholesale acquisition cost minus the beneficiary copay, plus a dispensing fee.

Start preparing now. Even though the Bridge doesn't launch until July 1, you can begin gathering documentation today. Get your BMI measured and recorded. Compile documentation of qualifying conditions. Talk to your prescriber about submitting the prior authorization to the CMS central processor once the program goes live.

What Happens After the Bridge?

The Bridge is designed as a temporary program running through December 31, 2027. CMS intends for it to transition into the longer-term BALANCE Model in Medicare Part D. If you use the Bridge in 2026, you may need to switch Part D plans during the Fall 2026 open enrollment period (October 15 to December 7) to ensure you're in a plan that supports BALANCE in 2027.

Separately, semaglutide was selected for Medicare drug price negotiation under the Inflation Reduction Act in 2025, with negotiated prices expected to take effect in 2027. This could further reduce costs for Medicare beneficiaries.

Common Questions

Can your provider prescribe through the Bridge even if they're not enrolled in Medicare? Yes — a provider does not need to be enrolled in Medicare to write a prescription or submit a PA for the Bridge, as long as they are not on the CMS Preclusion List. If your current Part D plan denies a PA for a GLP-1 medication, CMS encourages the plan to redirect your provider to the Bridge's central processor.

Medical Disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult a licensed healthcare provider before starting, stopping, or changing any medication. GLP-1 receptor agonists are prescription medications with potential side effects and contraindications. Compounded medications are not FDA-approved. Pricing, coverage, and program details are subject to change—verify directly with providers and insurers.