Medicare GLP-1 Bridge: A New Access Program

Starting in July, some Medicare beneficiaries will gain access to GLP-1 medications through a monthly flat fee. This temporary initiative will last one and a half years, concluding at the end of 2027. With less than two weeks before its launch, there are still questions about its operation.

Program Overview

The Medicare GLP-1 Bridge, described by the Centers for Medicare and Medicaid Services (CMS) as a ‘time-limited demonstration,’ will run from July 1, 2026, to December 31, 2027. Announced in December, the program will offer eligible Medicare Part D enrollees access to GLP-1 medications for a $50 monthly co-pay. Although GLP-1s are used for diabetes, obesity, and some heart conditions, this program is primarily available for weight management.

Eligibility and Medications

Federal law currently prohibits Medicare from covering weight loss medications. Organizations like the Obesity Care Advocacy Network (OCAN) support the program. OCAN Coordinator Cristy Gallagher sees it as a major step in combating obesity.

Eligible beneficiaries need a prescription from their doctor and a prior authorization from a medical provider. Covered medications include Wegovy, Zepbound, and Foundayo. If switching medications during the program, patients will need a new authorization form.

Operational Details

Pharmacists will send prescriptions to the program’s central processor, referred to as the Bridge PCN by CMS. CMS will not process prospective prior authorizations when prescribing. If the patient’s prescription is their first GLP-1, the claim will be rejected before an authorization form is issued. The form requires attestation that the patient does not have Type 2 diabetes, sleep apnea, or MASH fatty liver disease. Claims will only be processed after July 1.

The Medicare GLP-1 Bridge seeks to test whether providing access to GLP-1 products at a uniform CMS negotiated net price will help improve beneficiary outcomes and reduce long-term Medicare spending.

The monthly $50 co-pay will not count toward deductibles or out-of-pocket costs. The future of the program post-2027 remains undetermined, although there is public interest in its continuation.

Detailed Eligibility Criteria

Enrollees in a standalone prescription drug plan or Medicare Advantage coordinated care plan qualify. Participants in Special Needs Plans, employer/union group waiver plans, the Limited Income Newly Eligible Transition program, Tricare For Life, and dual Medicare and Medicaid beneficiaries are also eligible. Tricare For Life participants need Part D plan enrollment.

The ideal participants are at high risk of obesity-related diseases. Catherine Varney of the Obesity Medicine Association highlighted the extensive health risks linked to obesity. Eligibility is further defined by a minimum BMI requirement. Beneficiaries must be 18 or older with a BMI of 27 or above, along with conditions like prediabetes or cardiovascular issues. Those with a BMI of 30 or more must have additional health conditions, except for those with a BMI of 35 or higher.

Regulatory Concerns and Costs

The program sidesteps Medicare’s usual restrictions on weight loss drugs. Concerns exist about fraud, particularly with telehealth providers seeking Medicare reimbursement. Regulatory counsel Christopher Frisina notes the potential risks but acknowledges CMS’s preventive measures, including detailed authorization forms requiring coordination between providers and pharmacies.

CMS has not disclosed the program’s cost or enrollment numbers. An agency spokesperson confirmed the $50 copay per monthly GLP-1 supply but acknowledged the program’s operational differences from standard Medicare Part D coverage.