Medicare GLP-1 Bridge Program 2026: Eligibility, Timeline & Access Guide

Tier 1: BMI ≥35

• Beneficiary is at least 18 years old
• BMI ≥35 at time of GLP-1 therapy initiation
• Prescribed for weight reduction and maintenance in combination with lifestyle modification (structured nutrition and physical activity per FDA-approved label)

Tier 2: BMI ≥30 with Comorbidity

• Beneficiary is at least 18 years old
• BMI ≥30 at time of therapy initiation
• Diagnosis of one or more of:
  • Heart failure with preserved ejection fraction
  • Uncontrolled hypertension (systolic >140 mm Hg or diastolic >90 mm Hg despite concurrent treatment with two antihypertensive medications)
  • Chronic kidney disease stage 3a or above

Tier 3: BMI ≥27 with Cardiovascular or Metabolic Diagnosis

• Beneficiary is at least 18 years old
• BMI ≥27 at time of therapy initiation
• Diagnosis of one or more of:
  • Pre-diabetes (as defined by American Diabetes Association guidelines)
  • Previous myocardial infarction
  • Previous stroke
  • Symptomatic peripheral artery disease

CMS has clarified that eligible beneficiaries must meet clinical criteria at the time of GLP-1 therapy initiation. For example, if a beneficiary initiated therapy with a BMI of 37 but has a BMI of 34 at the time of a July 2026 prior authorization request, the provider should attest that the BMI ≥35 criterion was met at initiation.

Beneficiary Eligibility & Enrollment

To participate in the Medicare GLP-1 Bridge, beneficiaries must:

1. Be enrolled in a qualifying Part D plan type:

   • Standalone Prescription Drug Plan (PDP)
   • Medicare Advantage coordinated care plan with prescription drug coverage (MA-PD): HMO, HMO-POS, or Local/Regional PPO
   • Special Needs Plans (SNPs)
   • Employer/union group waiver plans (EGWPs)
   • Limited Income Newly Eligible Transition (LI NET) program

2. Meet clinical eligibility criteria (as outlined above)

3. Have a provider submit a prior authorization request and prescription for an eligible GLP-1 drug

Beneficiaries enrolled in private fee-for-service plans, section 1876 cost contract plans, section 1833 health care prepayment plans, PACE organizations, fallback plans, and religious fraternal benefit plans are not eligible, unless also enrolled in a standalone PDP.

The Medicare GLP-1 Bridge will be nationwide and available in all states and territories.

Prior Authorization Process

Access to GLP-1 medications through the Medicare GLP-1 Bridge requires provider-initiated prior authorization. Prior authorization requests will be submitted to the Central Processor (Humana) and should not be sent to CMS.

Key points:

• Provider requirement: The prescribing provider does not need to be enrolled in Medicare but must not be on the CMS Preclusion List for the drug to be coverable under the program.
• Timing: Prior authorization requests are not accepted prior to July 1, 2026.
• Central processor administration: Humana, the current administrator of the LI NET program, will serve as the central processor, managing prior authorization, claims adjudication, and payment to pharmacies.

Copay & Cost Structure

Eligible beneficiaries will have a $50 copay, which remains consistent regardless of:

• Which eligible GLP-1 drug is dispensed
• The specific formulation or strength
• The phase of the Part D benefit the beneficiary is in when filling the prescription

Critically, the $50 copay does not count toward TrOOP costs and is not subject to low-income cost-sharing subsidies. This means the copay does not accumulate toward the beneficiary's catastrophic coverage threshold.

Pharmacies will collect the $50 copay from the eligible beneficiary, and the central processor will process payment to the pharmacy at the wholesale acquisition cost of the drug, less the beneficiary copay, plus a dispensing fee and applicable sales tax.

Operational Timeline

Regulatory Authority

The Medicare GLP-1 Bridge operates under Section 402(a)(1)(A) of the Social Security Amendments of 1967, as amended and expressly made applicable to Part D by section 1860D-42(b) of the Social Security Act. This authority permits the Secretary to carry out demonstration projects to determine whether changes in payment or reimbursement methods would increase efficiency and economy of health services covered under Medicare.

Implications for Researchers

The Medicare GLP-1 Bridge represents a significant policy intervention in GLP-1 access and utilization patterns among Medicare beneficiaries. Researchers tracking obesity pharmacotherapy adoption, medication cost-sharing effects, and health outcomes in older adult populations should monitor:

• Utilization patterns: CMS will collect data on GLP-1 drug uptake, discontinuation rates, and adherence through the central processor.
• Equity considerations: The fixed $50 copay structure and exclusion of TrOOP counting may differentially affect beneficiary access across income levels and comorbidity profiles.
• Real-world outcomes: The 18-month demonstration window provides a natural experiment for studying the health effects of expanded GLP-1 access in a Medicare population.
• Transition to BALANCE: Data collected will inform the design of the permanent BALANCE Model in Part D, potentially reshaping how GLP-1 medications are covered and reimbursed in traditional Medicare.

Summary

The Medicare GLP-1 Bridge is a time-limited but nationwide program designed to expand access to three GLP-1 medications for eligible Medicare Part D beneficiaries. Eligibility hinges on clinical criteria assessed at therapy initiation, and enrollment requires provider-submitted prior authorization through Humana's central processor. With a fixed $50 copay and manufacturer-negotiated pricing at $245 per monthly supply, the program operates independently of standard Part D cost-sharing and benefit phases. The program's 18-month duration provides a critical window for policy evaluation and real-world data collection before potential permanent implementation of the BALANCE Model in Medicare Part D.

Frequently Asked Questions

What is the difference between the Medicare GLP-1 Bridge and standard Part D coverage?

The Medicare GLP-1 Bridge operates outside the standard Part D benefit structure. Part D deductibles do not apply, the $50 copay does not count toward TrOOP costs, and low-income subsidies are not available for the copay. Part D sponsors do 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 for eligible beneficiaries to access these drugs.

Can a beneficiary who initiated GLP-1 therapy before Medicare enrollment qualify for the Medicare GLP-1 Bridge?

Yes. Eligible beneficiaries must meet clinical criteria at the time of GLP-1 therapy initiation, including beneficiaries who initiated therapy prior to enrolling in Medicare Part D and/or prior to the July 1, 2026 launch of the Medicare GLP-1 Bridge. The provider must attest that the beneficiary met criteria when therapy was first started.

Which Zepbound® formulation is covered?

Only the Zepbound® KwikPen® formulation is included in the Medicare GLP-1 Bridge. Single-dose vial and single-dose pen formulations are not covered.

Is the $50 copay subject to low-income cost-sharing assistance?

No. No part of the $50 copay counts toward the beneficiary's TrOOP costs, and low-income cost-sharing subsidies do not apply to any portion of the copay.

When does the Medicare GLP-1 Bridge end?

The Medicare GLP-1 Bridge will operate between July 1, 2026, and December 31, 2027. The program will be extended through December 31, 2027, allowing CMS to collect utilization data for potential implementation of the BALANCE Model in Part D.