Starting July 1, 2026, a new 18-month pilot program allows some Medicare Part D members to get GLP-1 weight-loss medications like Wegovy, Foundayo, or Zepbound for a $50 monthly copay. This "Medicare GLP-1 Bridge" aims to make these costly drugs more accessible to eligible individuals, potentially benefiting an estimated 3.8 million beneficiaries. The program will run through December 31, 2027, bridging the gap before a potential longer-term solution.
Eligibility for the program is based on specific clinical criteria. Beneficiaries must be at least 18 years old and enrolled in an eligible Part D stand-alone plan or Medicare Advantage plan that includes prescription drug coverage. Clinical requirements include a BMI of 35 or higher; a BMI of 30 or higher with conditions like chronic kidney disease (stage 3a or above), heart failure with preserved ejection fraction, or uncontrolled high blood pressure; or a BMI of 27 or higher with prediabetes, a previous heart attack, previous stroke, or symptomatic peripheral artery disease. Providers must attest that the GLP-1 is prescribed for weight management alongside lifestyle changes.
Crucially, the $50 copays under this program do not count toward Part D deductibles or the $2,100 out-of-pocket spending limit for 2026. This means beneficiaries will still need to meet their Part D out-of-pocket costs separately. Additionally, those receiving the low-income subsidy (Medicare Extra Help program) cannot use that assistance for these GLP-1 drugs. The program operates outside of Part D plan coverage, with an external firm, Humana, processing claims and prior authorizations. CMS aims for a 72-hour turnaround for prior authorization decisions. This program specifically targets beneficiaries without existing medically covered indications for GLP-1s through their Part D plan, excluding those with type 2 diabetes, obstructive sleep apnea, MASH, or those prescribed GLP-1s for cardiovascular risk reduction.
