In the latest effort by the Trump administration to reduce costs and increase access to anti-obesity medications like Ozempic and Wegovy (also known as GLP-1s), the Centers for Medicare & Medicaid Services (“CMS”) announced that beginning July 1, 2026, eligible Medicare beneficiaries can access certain GLP-1 weight loss medications for just $50 per month through the new “Medicare GLP-1 Bridge” program (the “Bridge”). The $50 copay will be the beneficiary’s total out-of-pocket cost. The Bridge is designed as a temporary demonstration program that will run through December 31, 2027, and is intended to lay the groundwork for the new Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (“BALANCE”) Model. The BALANCE Model, launching in 2027, is intended to increase access to GLP-1 medications and other healthy lifestyle interventions directly through Medicare Part D.
The following summarizes the key features of the Bridge and what stakeholders should know as the program’s July 1 launch approaches.
Patients
- The Bridge program is nationwide and available in all states and territories.
- Covered drugs include Foundayo, Wegovy (injection and tablets), and Zepbound, when prescribed to reduce excess body weight.
- Additional coupons or discounts may not be used to reduce the $50 copay further.
- To qualify, beneficiaries must meet prior authorization criteria and be enrolled in a standalone Prescription Drug Plan (“PDP”) or Medicare Advantage plan offering prescription drug coverage (“MA-PD”).
- Clinical criteria are assessed at the time GLP-1 therapy was first initiated, including for beneficiaries who started therapy before enrolling in Medicare Part D or before the July 1, 2026 launch of the Bridge.
- Key clinical eligibility criteria include: (i) a body mass index (BMI) of 35 or greater; (ii) a BMI of 30 or greater with a diagnosis of either heart failure, uncontrolled hypertension, or chronic kidney disease; or (iii) a BMI of 27 or greater with a diagnosis of either pre-diabetes, previous heart attack, previous stroke, or symptomatic peripheral artery disease. Beneficiaries should consult with their healthcare provider to determine whether they meet the applicable clinical criteria for the Bridge.
Providers
- To refer a patient to the Bridge, a provider must submit a prior authorization request and prescription for an eligible GLP-1 medication through a centralized process managed by CMS.
- For patients already on GLP-1 therapy, providers should attest that the patient met the clinical criteria at the time therapy was initiated.
- Providers do not need to be enrolled in Medicare to refer a patient to the Bridge, but the provider must not appear on CMS’s Preclusion List.
Pharmacies
- Pharmacies do not need to opt in to participate in the Bridge. CMS and Humana, which has been selected as the central processor (as detailed below), will be providing additional instructions on the pharmacy claims process for the Bridge in the coming months.
- Pharmacies will collect the $50 copay from the patient and Humana will reimburse the pharmacy at the Wholesale Acquisition Cost of the drug, less the copay, plus a dispensing fee and, as applicable, sales tax.
- The Bridge will be the primary payor for covered products and will not coordinate benefits with other payors.
- Claims must be submitted electronically using the NCPDP Telecommunication Standard. Paper claims and direct member reimbursements will not be accepted.
Payors
- Part D sponsors carry no risk for Bridge-covered drugs and do not need to opt in. The Bridge operates outside of the Medicare Part D coverage and payment flow.
- CMS has designated Humana, the current LI NET program administrator, as the central processor to manage prior authorization, claims adjudication, and pharmacy payment.
- Plans that receive a prior authorization request for a Bridge-covered drug for weight management should redirect providers to the central processor. CMS has made clear that it will monitor formulary practices to ensure plans do not improperly shift coverage decisions from the Part D benefit into the Bridge.
- CMS will be working in cooperation with the NCPDP to create a guidance document to assist with implementation and standard messaging that plans should utilize with providers.
The Medicare GLP-1 Bridge represents a significant step in CMS’s broader effort to improve accessibility and affordability of prescription drugs for Medicare beneficiaries. As CMS continues to release implementation guidance in the coming months, stakeholders should monitor developments closely and prepare for the program’s July 1, 2026 launch.
Sources:
- Coming Soon: CMS to Provide $50 Monthly Access to GLP-1 Medications for Medicare Beneficiaries, Ctrs. for Medicare & Medicaid Servs. (May 6, 2026), https://www.cms.gov/newsroom/press-releases/coming-soon-cms-provide-50-monthly-access-glp-1-medications-medicare-beneficiaries.
- Medicare GLP-1 Bridge, Ctrs. for Medicare & Medicaid Servs., https://www.cms.gov/medicare/coverage/prescription-drug-coverage/medicare-glp-1-bridge (last accessed May 8, 2026).
