The federal Medicare program in the United States has officially launched its GLP-1 Bridge Program as of July 1. Eligible Medicare Part D enrollees can now access specific GLP-1 weight-loss medications for a monthly co-payment of just $50. This pilot initiative is scheduled to run for 18 months, concluding on December 31, 2027.

Program Scope

The program covers medications including Novo Nordisk's Wegovy (injectable and tablet forms), Eli Lilly's Zepbound KwikPen, and Lilly's oral weight-loss drug Foundayo. It is important to note that this pilot operates independently from standard Medicare Part D benefits. Claims processing, including prior authorizations and reimbursements, will be handled through a centralized system established by the Centers for Medicare & Medicaid Services (CMS), bypassing pharmacy benefit managers or individual Part D plans.

Eligibility Requirements

To qualify, patients must meet several criteria. They must be at least 18 years old, enrolled in Medicare Part D or a Medicare Advantage plan that includes drug coverage, and have a prescription from their doctor for an eligible GLP-1 medication specifically for weight loss.

Clinical Criteria

The clinical eligibility standards are based on the patient's health status at the time of initiating therapy. Qualification requires one of the following conditions:

A body mass index (BMI) of 35 or higher.

A BMI of 30 or higher, accompanied by heart failure with preserved ejection fraction, uncontrolled hypertension, or chronic kidney disease (stage 3a or higher).

A BMI of 27 or higher, accompanied by pre-diabetes, a history of prior heart attack or stroke, or symptomatic peripheral artery disease.

Additionally, patients cannot have previously received a GLP-1 medication for another indication, such as type 2 diabetes, through their Part D plan.

Program Impact and Structure

According to an analysis by KFF, approximately 3.8 million Medicare beneficiaries meet the eligibility requirements for coverage under this program.

Because the Bridge Program operates outside of Part D, the patient's $50 monthly co-payment does not count toward their annual Part D out-of-pocket spending limit. This cost also cannot be offset by the federal Extra Help program.

Future Considerations

It is crucial to understand that this is a temporary pilot program. Unless CMS extends it or Congress passes legislative changes, beneficiaries risk a disruption in their medication coverage after the end of 2027.