Medicare GLP-1 bridge eligibility: who qualifies

The Medicare GLP-1 Bridge is a temporary CMS demonstration that runs from July 1, 2026 through December 31, 2027. It is separate from standard Part D coverage and separate from CMS’s longer-term BALANCE model. It applies to certain GLP-1 weight-management medicines during the demonstration window. Ask your plan or pharmacist to confirm whether your coverage request is being processed under the Bridge versus regular Part D rules.

The Bridge is designed for eligible Part D enrollees, and it uses prior authorization. Have your Medicare information ready, including your Part D plan details and your current medication list. If you’re covered for GLP-1s through another route (for example, a different benefit design), your plan may still process it differently. A pharmacist or your plan’s member services line can tell you which pathway applies to you.

The Bridge prior authorization criteria include age 18+ plus one of several BMI pathways. One pathway is BMI of 35 or higher. Another pathway is BMI of 30 or higher with certain heart, kidney, or blood-pressure conditions. A third pathway is BMI of 27 or higher with prediabetes, prior stroke or heart attack, or symptomatic peripheral artery disease (PAD). Your clinician’s office can document your most recent height, weight, and BMI in the format your plan expects.

If your eligibility depends on a qualifying condition, collect clear proof from your medical record. Examples include a diagnosis list, recent labs showing prediabetes, or hospital records showing a prior heart attack or stroke, if those apply to you. For symptomatic PAD, plans may look for clinician notes that describe symptoms and diagnosis. Don’t guess which document is “best”—ask your prescriber’s office or the plan what they want for prior authorization.

The Bridge covers Wegovy (all forms), Foundayo, and Zepbound KwikPen. Coverage is still subject to prior authorization and your plan’s processing steps. If you are currently using Ozempic or Mounjaro, those are different brand indications and may be handled under different coverage rules. If you’re using compounded versions, ask your prescriber and pharmacist how to transition your paperwork for an FDA-approved product under your plan’s process.

Under the Bridge, eligible Part D enrollees pay a $50 per month copay. This copay does not count toward your deductible or your out-of-pocket maximum. This is a program design detail that can surprise people who expect their spending to accumulate the usual way. Confirm with your plan how the $50 will appear at the pharmacy and whether any additional costs apply to you under your plan’s setup.