Starting July 1, Medicare is implementing a new 18-month pilot program to make popular GLP-1 weight-loss drugs like Wegovy, Foundayo, and Zepbound more affordable for eligible Part D members. This "Medicare GLP-1 Bridge" program will allow qualified beneficiaries to access these medications for a $50 monthly copay. The program, which runs through the end of 2027, is designed to operate outside of standard Part D coverage, meaning the $50 copays will not count towards Part D deductibles or the $2,100 out-of-pocket spending limit for 2026, nor will they be eligible for the Medicare Prescription Payment Plan.
An estimated 3.8 million beneficiaries, representing about 8% of 2023 Part D enrollees, could be eligible for this program. To qualify, individuals must be at least 18 years old and meet specific clinical criteria, such as a BMI of 35 or higher, or a BMI of 30 or higher with co-existing conditions like chronic kidney disease or certain heart conditions. Those with a BMI of 27 or higher may also qualify if they have prediabetes, a history of heart attack or stroke, or symptomatic peripheral artery disease. The program requires providers to attest that the GLP-1 is prescribed for weight management in conjunction with lifestyle changes.
The bridge program specifically targets individuals who do not have a medically covered indication for GLP-1s through their existing Part D plan, such as type 2 diabetes, obstructive sleep apnea, or MASH (metabolic dysfunction-associated steatohepatitis), as these conditions generally allow for Part D coverage. Humana will process program claims, prior authorizations, and pharmacy payments, not the Part D plans themselves. This initiative, initially conceived as a six-month bridge to a larger pilot, was extended to 18 months indefinitely after a planned January 2027 test was postponed.
While GLP-1s are costly, research suggests that expanded use could lead to significant healthcare savings. Medicare could spend an estimated $65.9 billion on GLP-1s over the next decade, but this might be offset by an $18.2 billion reduction in other healthcare treatment costs, leading to a net increase of $47.7 billion. The $50 monthly copay represents a steep discount from the cash-pay prices, which can range from $149 to over $1,000 per month depending on the medication. The Trump administration's agreement with Eli Lilly and Novo Nordisk involves selling these drugs to Medicare for $245 for a month's supply.
To enroll, providers must submit a prior authorization request and a prescription for an eligible GLP-1 drug. CMS aims for a 72-hour turnaround for prior authorization decisions. Once the initial 28 or 30-day prescription is approved, subsequent fills typically won't require re-authorization unless the beneficiary switches medications. Covered medications include Wegovy injections and tablets, Foundayo tablets, and the Zepbound KwikPen; single-dose Zepbound vials or pens are not covered.
