Current as of May 15, 2026
An Overview of the Extended Medicare GLP-1 Bridge
On April 21, the Centers for Medicare & Medicaid Services (CMS) announced an extension of its new Medicare GLP-1 Bridge. Instead of a six-month duration, CMS will provide eligible members access to certain GLP-1 drugs for weight loss for a 1.5-year duration.
The Medicare GLP-1 Bridge will be available in all states and territories from July 1, 2026 to December 31, 2027.
- The program will operate directly between the provider and CMS; it is NOT part of the Medicare Part D benefit and does not involve carriers or Medicare plans
- Eligible members will have access to three products only: Wegovy (injection and tablets), Zepbound (KwikPen®), and Foundayo
- To be eligible, Medicare members need to be enrolled in a Part D prescription drug plan in 2026 and 2027 (MAPD or PDP) and meet certain prior authorization criteria
- Co-pays will be $50 for a one-month supply
- Any out-of-pocket (OOP) costs do not contribute to a member’s deductible or OOP maximum
- A provider can refer a member to the Medicare GLP-1 Bridge by submitting a prior authorization request to CMS and writing a prescription for an eligible GLP-1 drug for a covered use
For more detail on the Medicare GLP-1 Bridge, see our FAQs section.
The Delayed BALANCE Model
CMS originally defined the Medicare GLP-1 Bridge as a short-term program that would serve as a bridge to the long-term, voluntary BALANCE Model. The BALANCE model would have been part of the Part D benefit. Carriers were invited to apply to CMS to participate.
In the same April 21 announcement that extended the Medicare GLP-1 Bridge, CMS delayed the implementation of the BALANCE Model for plan year 2027 because the 80% threshold for carrier participation was not met. This delay, and the extension of the Medicare GLP-1 Bridge, will allow CMS more time to collect data on GLP-1 utilization to share with carriers ahead of a potential BALANCE Model implementation. It is not yet known whether the BALANCE Model will launch, which carriers will participate, which will include employer group plans, and what copays they would offer.
Program FAQs
The responses below are primarily sourced from the CMS.gov website. For the latest updates to the Medicare GLP-1 Bridge, visit:
https://www.cms.gov/medicare/coverage/prescription-drug-coverage/medicare-glp-1-bridge
General
Q1: Will my Medicare members have GLP-1 drug coverage for weight loss under their Medicare Part D benefit?
A1: No, the Medicare GLP-1 Bridge is a short-term program that will operate directly between the provider and CMS. It will not be part of the Medicare Part D benefit and does not involve carriers or Medicare plans. 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 members 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.
Q2: What is the impact of the BALANCE Model delay?
A2: The Medicare GLP-1 Bridge was extended through December 31, 2027, providing eligible Medicare Part D beneficiaries with access to certain GLP-1 drugs and allowing CMS to collect additional data on GLP-1 utilization to share with Part D plan sponsors ahead of potential implementation of BALANCE in Part D.
Medicare GLP-1 Bridge Eligibility & Participation
Q3: Are all Medicare members eligible for the Medicare GLP-1 Bridge?
A3: The Medicare GLP-1 Bridge will be nationwide and available in all states and territories. To be eligible, Medicare members must be enrolled in a Part D prescription drug plan in 2026 and 2027 (MAPD or PDP) and meet certain prior authorization criteria. (See A4 for criteria.) Part D beneficiaries in employer/union group waiver plans (EGWPs) are eligible to participate. Additionally, dually-eligible beneficiaries who are enrolled in eligible Part D plan types and meet the prior authorization criteria will have access to GLP-1 drugs via the Medicare GLP-1 Bridge.
Q4: What clinical criteria must a member meet to qualify?
A4: For a member to qualify, a provider must submit a prior authorization request that attests the member meets the following criteria:
- The member is prescribed the requested drug to reduce excess body weight and maintain weight reduction in combination with current and ongoing lifestyle modification including structured nutrition and physical activity consistent with the applicable FDA approved label, AND
- The member is at least eighteen (18) years of age and has a BMI greater than or equal to thirty-five (≥35) at the time of initiation of GLP-1 therapy, or
- The member is at least eighteen (18) years of age and has a BMI greater than or equal to thirty (≥30) at the time of initiating GLP-1 therapy with a diagnosis of one or more of the following: (A) heart failure with preserved ejection fraction, (B) uncontrolled hypertension (defined as systolic blood pressure above 140 mm Hg or diastolic blood pressure above 90 mm Hg, despite concurrent treatment with two antihypertensive medications), or (C) chronic kidney disease stage 3a or above, or
- The member is at least eighteen (18) years of age and has a BMI greater than or equal to twenty-seven (≥27) at the time of initiating GLP-1 therapy with a diagnosis of one or more of the following: (A) pre-diabetes (as defined by American Diabetes Association guidelines), (B) previous myocardial infarction, (C) previous stroke, or (D) symptomatic peripheral artery disease
Q5: Does a member need to meet the clinical criteria at the time of the prior authorization request, or at the time they first initiated GLP-1 therapy?
A5: Eligible beneficiaries must meet the clinical criteria at the time of GLP-1 therapy initiation. This includes 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.
Q6: Who will serve as the central processor for the Medicare GLP-1 Bridge responsible for managing prior authorization, claims adjudication, and payment to pharmacies?
A6: CMS will be utilizing Humana, the current administrator of the Limited Income Newly Eligible Transition (LI NET) program, as the central processor for the Medicare GLP-1 Bridge. The LI NET infrastructure provides the end-to-end operational capabilities and national scale that are critical to provide broad access to GLP-1 drugs to Medicare beneficiaries via the GLP-1 BRIDGE starting July 1, 2026.
Q7: How will the central processor handle coordination of benefits and claims processing?
A7: The Medicare GLP-1 Bridge will be the primary payer for products covered under the Medicare GLP-1 Bridge and will not coordinate benefits with other payers. Coupons and discount programs may not be applied to Medicare GLP-1 Bridge claims.
The central processor will process claims submitted electronically using the NCPDP Telecommunication Standard. Paper claims and direct member reimbursements will not be accepted by the central processor.
Q8: What GLP-1 drugs will be available through the Medicare GLP-1 Bridge?
A8: Eligible members will have access to three products only: Wegovy® (injection and tablets), Zepbound® (KwikPen®), and Foundayo®.
Q9: How can a medical provider refer a member to the Medicare GLP-1 Bridge?
A9: The provider needs to submit a prior authorization request and a prescription for an eligible GLP-1 drug for a use covered under the Medicare GLP-1 Bridge. (See A4 for criteria.) CMS will conduct outreach and education to help providers understand when to submit a prior authorization request for an eligible GLP-1 drug to the member’s Part D plan versus the central processor.
Q10: Does a provider have to be enrolled in Medicare to refer a member to the Medicare GLP-1 Bridge?
A10: A provider does not need to be enrolled in Medicare in order to write a prescription or submit a prior authorization request for products provided under the Medicare GLP-1 Bridge to an eligible member. However, the provider must not be on the Preclusion List.
Pharmacy Engagement in the Medicare GLP-1 Bridge
Q11: Do pharmacies need to opt-in to participate in the Medicare GLP-1 Bridge?
A11: No, pharmacies do not need to opt-in to participate. CMS and the central processor will provide additional technical instructions on pharmacy claims processes for the Medicare GLP-1 Bridge in the coming months.
Q12: Where will pharmacies send claims for the Medicare GLP-1 Bridge?
A12: CMS has established a Bank Identification Number (BIN) and Processor Control Number (PCN) that is specific to the Medicare GLP-1 Bridge (028918 MEDDGLP1BR). A payer sheet will be forthcoming. CMS will conduct outreach and education to help pharmacists understand when to submit a claim request for an eligible GLP-1 drug to the member’s plan versus the central processor.
Q13: How will claims be paid under the Medicare GLP-1 Bridge?
A13: Pharmacies will collect a $50 copay amount from the eligible member, and the central processor will process payment to the pharmacy. Pharmacies will be reimbursed by the central processor at the wholesale acquisition cost of a drug, less the member copay, plus a dispensing fee and, as applicable, sales tax.
Part D Sponsor Interactions with the Medicare GLP-1 Bridge
Q14: What should Part D sponsors do if they receive a prior authorization request for a Medicare GLP-1 Bridge-covered drug for weight management?
A14: If a provider submits a prior authorization request to the Part D plan for a GLP-1 product that is not covered by the Part D plan but may be eligible for coverage under the Medicare GLP-1 Bridge, CMS strongly encourages the plan sponsor to return a message directing the provider to contact the central processor. CMS will work with the National Council for Prescription Drug Programs (NCPDP) to create a guidance document to help the industry implement the program within the adopted NCPDP standards; we anticipate the guidance will include standard messaging that plans should utilize with providers.
CMS reminds plan sponsors of their obligations related to coverage determinations under 42 CFR Part 423 Subpart M. The Medicare GLP-1 Bridge does not modify beneficiary appeal rights, including exception requests, in relation to their Part D coverage.
Q15: How does the Medicare GLP-1 Bridge interact with drug coverage from a Medicare Part D plan?
A15: Under the Medicare GLP-1 Bridge, participating manufacturers will provide eligible GLP-1 drugs at a net price of $245 per monthly supply. Coverage of eligible GLP-1 drugs furnished under the Medicare GLP-1 Bridge is provided outside of the Part D benefit payment flow and coverage. As such, no part of the $245 net price for eligible GLP-1 drugs prescribed for uses covered under the Medicare GLP-1 Bridge would count toward an eligible beneficiary’s gross covered prescription drug costs (GCPDC), and no part of the $50 copay would count toward the beneficiary’s true out-of-pocket costs (TrOOP) under their Part D plan. In addition, the $50 copay for eligible beneficiaries would remain the same, regardless of the phase of the Part D benefit an eligible beneficiary is in when they fill a prescription for an eligible GLP-1 drugs covered under the Medicare GLP-1 Bridge. Similarly, low-income cost-sharing subsidies would also not apply to any portion of the copay.
Beneficiaries who are prescribed an eligible GLP-1 drug for a use that is coverable under the basic Medicare Part D benefit, regardless of whether the eligible GLP-1 drug is on the Part D plan’s formulary (e.g., Zepbound® for the treatment of moderate to severe obstructive sleep apnea (OSA) in adults with obesity; Wegovy® to reduce the risk of major adverse cardiovascular (CV) events in adults with established CV disease and either obesity or overweight) would not qualify for coverage of that eligible GLP-1 drug under the Medicare GLP-1 Bridge. Part D plan sponsors must continue to follow their existing formulary exception processes for these requests. CMS will monitor Part D formulary and utilization management practices, including formulary exception processes, to ensure plans do not shift coverage or access decisions from the Part D benefit to the Medicare GLP-1 Bridge.
Interaction with the Medicare Drug Price Negotiation Program
Q18: How does the maximum fair price (MFP) announced under the Medicare Drug Price Negotiation Program for Ozempic; Rybelsus; Wegovy relate to the Medicare GLP-1 Bridge?
A18: Ozempic; Rybelsus; Wegovy is a selected drug for initial price applicability year 2027 of the Medicare Drug Price Negotiation Program (Negotiation Program). The MFP for Ozempic; Rybelsus; Wegovy, negotiated under the Negotiation Program, does not become effective until January 1, 2027. By contrast, the Medicare GLP-1 Bridge is a distinct, time-limited demonstration that will operate between July 1, 2026, and December 31, 2027. For 2026, the two initiatives operate independently as no products provided under the Medicare GLP-1 Bridge are subject to an MFP during the 2026 demonstration period. More information on the 2027 demonstration period is forthcoming.
