Author: Beverly Thomassian, RN, MPH, CDCES, BC-ADM
CEO & President, DiabetesEd Services
You might have already started receiving questions from patients and your colleagues about the new Medicare Bridge Benefits for the GLP-1 weight loss medications. This article provides a brief overview of eligibility, covered medications and inclusion criteria. We also provide a summary for prescribers steps to successfully send a prescription to your local pharmacy. Information on help lines and other resources are also included.
On July 1, 2026, the Centers for Medicare & Medicaid Services (CMS) officially launched the Medicare GLP-1 Bridge Program that runs through December 31, 2027.
The Medicare Bridge is a nationwide demonstration program that provides eligible beneficiaries with access to select GLP-1 medications for a predictable copay of $50 per month. By capping the monthly copay for select GLP-1 drugs, this program addresses a critical affordability gap for eligible beneficiaries. For your healthcare teams, this initiative may initiate a practice-management shift and require prescribing adjustments, including additional paperwork.
The Covered Formulary: Approved Agents and Formulations
The program does not offer blanket coverage for all anti-obesity medications. CMS has restricted the Bridge program to three specific, high-profile GLP/GIP therapies prescribed strictly for chronic weight management:
- Foundayo® (tablets)
- Wegovy® (injection and tablets)
- Zepbound® (KwikPen®)
Note: The single-dose Zepbound® pen and Zepbound® vials are NOT covered
You can also find additional detailed information in the Medicare Prescriber Fact Sheet, which includes an overview of the process and key details about the Medicare GLP-1 Bridge program.
Who Qualifies to Use the Bridge Program – 1st Step
In order to quality, clinicians must consider the following administrative criteria:
- The patient must be enrolled in a standard Medicare Part D prescription drug plan or a Medicare Advantage plan that includes drug coverage.
- Second, and most importantly, the patient must not already be eligible to receive a GLP-1 through their standard Part D plan.
Exceptions to Bridge Eligibility
The individual must continue to obtain their GLP-1 directly through standard Part D coverage if they have a primary diagnosis of Type 2 diabetes, moderate-to-severe obstructive sleep apnea, or noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH).
The Bridge program is explicitly reserved for beneficiaries seeking the drug solely for weight reduction or weight maintenance.
First Step - Evaluate if patients meet the inclusion criteria
1st Tier Inclusion Criteria: (BMI ≥ 35)
- CMS has built three strict clinical tiers based on the Body Mass Index (BMI) at the time of initiating therapy. The first inclusion tier is the most straightforward.
- Any beneficiary who is at least 18 years of age and presents with a BMI of 35 or higher automatically qualifies for the Bridge program. For this group, no secondary cardiovascular, metabolic, or renal comorbidities are required to secure clinical approval.
2nd Tier Inclusion Criteria: (BMI 30 to 34.9)
The second tier covers those with a baseline BMI between 30 and 34.9. To successfully qualify in this tier, the provider must document at least one of three specific secondary health complications in the medical record:
- Heart failure with preserved ejection fraction (HFpEF).
- Uncontrolled hypertension, which is defined as blood pressure greater than 140/90 that remains elevated despite the documented use of two or more distinct antihypertensive medications.
- Chronic Kidney Disease (CKD) classified strictly at Stage 3a or above.
3rd Tier Inclusion Criteria: (BMI 27 to 29.9)
The final clinical tier opens the program to those with lower BMIs, targeting individuals with a baseline BMI between 27 and 29.9. Because the weight elevation is less severe, CMS requires documentation of highly specific cardiovascular or metabolic warning signs. To qualify, an individual must possess a confirmed history of at least one of the following conditions:
- Prediabetes, defined strictly by current American Diabetes Association (ADA) guidelines.
- A documented history of a prior myocardial infarction (heart attack).
- A documented history of a prior cerebrovascular accident (stroke).
- Symptomatic peripheral artery disease (PAD) affecting the limbs.
If your patient meets the criteria of any of these tiers, you can move on to prescribing one of the 3 approved medications.
2nd Step: Submitting the Prescription | Read this before sending Rx to pharmacy
To successfully transition an eligible patient onto the Bridge program, clinics will need to prepare for a distinct workflow.
First Step:
If you think that the patient is eligible for coverage under Medicare GLP-1 Bridge, before sending order to pharmacy – read these important instructions.
- Transmit the prescription to the pharmacy using your standard process
- Direct the pharmacist to send the claim directly to Medicare GLP-1 Bridge by including an obesity diagnosis code (the E66 family)
- Indicating “SEND TO BRIDGE FOR WEIGHT MANAGEMENT” on the prescription in the Note field if electronic, or as an annotation if non-electronic.
- If the pharmacist doesn’t get that direction, they might send the claim to your patient’s Part D plan.
- Your patient’s Part D plan may initiate a prior authorization request or reject the claim.
Second Step:
Once the administrative baseline is verified, the provider will be required to submit a specialized CMS Prior Authorization (PA) Form detailing the patient’s exact metric history.
You must wait (up to 72 hours) to get the request from the pharmacy electronically or by fax for your patients to be covered under Medicare GLP-1 Bridge.
Please see the Prescriber Fact Sheet for much more detailed information.
The Bridge Program Operates Outside Medicare Part D
The Medicare GLP-1 Bridge will operate outside of the Medicare Part D benefit’s coverage and payment flow. As a result, Part D sponsors will not carry risk for eligible GLP-1 drugs furnished under the Medicare GLP-1 Bridge, and Part D sponsors do not have to opt in to the Medicare GLP-1 Bridge for eligible beneficiaries to access these drugs beginning July 1, 2026.
In 2026, CMS will use a single central processor to manage prior authorization, claims adjudication, and payment to pharmacies for the Medicare GLP-1 Bridge.
Because it completely bypasses standard plan frameworks, the $50 monthly copay does not count toward a patient’s annual Part D deductible or the maximum out-of-pocket spending cap. Additionally, cost-sharing assistance like the Low-Income Subsidy (Extra Help) program cannot be applied to this $50 flat fee.
Need Help? The Medicare GLP-1 Bridge Prescriber Call Center
The call center is available at 855-273-0102 Monday through Friday from 8am – 7pm ET. Representatives are available to assist prescribers with questions about the prior authorization process or the status of a prior authorization request.
Prescribers can also find additional information in the Prescriber Fact Sheet, which includes an overview of the process and key details about the Medicare GLP-1 Bridge for prescribers.
For more information, please visit:
Medicare GLP-1 Bridge Information Page: https://www.cms.gov/medicare/coverage/prescription-drug-coverage/medicare-glp-1-bridge/information-providers
Beverly Thomassian, RN, MPH, CDCES, BC-ADM
CEO & President, DiabetesEd Services
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