Where can Medicare beneficiaries go for GLP-1s? Under the BRIDGE, of course

If you have been keeping up with Medicare drug coverage news, you know the debate for GLP-1 coverage has been hot and cold to say the least. The newest update, the Medicare GLP-1 Bridge Program, will get your beneficiaries coverage for weight loss drugs like Wegovy for only $50 dollars a month. But what’s the catch? We have the whole story here for you.

What is the Bridge?

The Medicare GLP-1 Bridge demonstration is a short-term solution to the rising costs of GLP-1s. It will allow Medicare beneficiaries with Part D to access Foundayo, Wegovy injections and tablets, and the KwikPen formulation of Zepbound from July 1 until Dec 31, 2027. BRIDGE extends across all states and territories in the US.

Essentially, CMS is running this as a mini experiment: How can we get as many people to reap the health benefits of a GLP-1 as possible without breaking the bank. The cost of these drugs is the only turn off, with the average GLP-1 user costing $15,000 a year. This plan gets the drugs to beneficiaries without any pressure on carriers to fork out the cash for the medications.

CMS has negotiated a cost to them of $245 per monthly dose of each GLP-1, and the beneficiary will pay a $50 copay per dose. Since this program is operating completely separately from any other coverage, this copay will not count towards Part D cost accumulators, and the price stays the same regardless of what Part D coverage phase the beneficiary is in. 

The hope is that this will allow future programs to work more efficiently. Then, once the process is as streamlined and cost-efficient as possible, the torch can be passed to the carriers. Theoretically, they will then pay less for costly treatments and procedures down the road for the conditions that pop up from untreated obesity.

How does this work?

Beneficiaries must have Part D coverage to participate. They can go to a medical provider and ask for a prior authorization request and a prescription for a GLP-1. If the provider thinks the beneficiary is willing to undergo lifestyle modifications, like structured nutrition and physical activity plans, and meet the medical criteria, such as a high BMI or a related chronic condition like hypertension or pre-diabetes, they can prescribe away. 

GLP-1s cannot be covered under the BRIDGE program for other diagnoses that are covered by Part D, like sleep apnea or cardiovascular disease.  

Didn’t we already BALANCE that out?

Well, yes, BALANCE started in May 2026, and would have helped beneficiaries pay for GLP-1s for weight loss through Part D. But, the portion of the model affecting Part D has been delayed until 2027. This coverage gap, until BRIDGE stepped in, would have exposed Part D beneficiaries using GLP-1s to full price costs in the meantime from May 2026 until January 2027. Many simply cannot afford that, and would have gone without their medications.

CMS will continue to accept state applications to participate in the BALANCE model until the end of July, and states can start this model when they choose between now and the end of the year. As of writing, 13 states have signed on, with Michigan not being one of them. But hopefully, the effort CMS will put into negotiating GLP-1 prices will entice more states to come on board.

What is the benefit of BRIDGE in comparison to other programs?

Before, Part D only paid for GLP-1s for diabetes treatment. Carriers were footing the bill for these drugs, and in an effort to control costs, CMS banned drugs of any kind from getting covered for weight loss purposes. But this program operates totally separate from all other programs, so it does not use the same channels for managing prior authorization, claims adjudication, and payments. Sponsors do not have to opt in; they just get to reap the benefits of their customers getting GLP-1 coverage without having to foot any of the bill.

What happens when we get to the other side of the BRIDGE?

Then BALANCE will take over, and Part D plans that opted into the BALANCE model will take on the responsibility of paying for these prescriptions. But remember, BALANCE is voluntary and requires state sign-on, which only 13 states have done. So what will happen to those living in nonparticipating states is yet to be determined. Worst-case scenario, they are made to pay full price if they want to continue.

But, the good news is that states can be added into the fold after the deadline passes at the discretion of CMS.

Weren't we negotiating the prices of these drugs anyway?

Yes. Wegovy was named on the Inflation Reduction Act's list of negotiated drugs in 2026. This doesn't have any direct affect on those negotiations, but it might be an indicator of what those drug prices could be in the future, whether they reach that price through the IRA negotiations or just through this BRIDGE demonstration. 

What does this mean for me?

As an agent, you should be addressing this with your clients. If they mention an interest in getting on a GLP-1, tell them about this program, but make sure they understand that this might not be a permanent solution. And if they are already on a GLP-1, they could get a prior authorization sent for covered use if they would like to get their drug for a lower cost, even if it is only temporary.