Medicare GLP-1 Bridge Program coverage for selected GLP-1 weight-loss drugs
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Governs a short-term national program (July 1, 2026–Dec 31, 2027) providing selected GLP-1 weight-loss drugs outside Medicare Part D for qualifying people with Medicare Part D coverage; specifies eligible products, eligibility criteria, cost sharing, and exclusions for this announcement window.
Starting July 1, 2026, Medicare GLP-1 Bridge covers certain GLP-1 weight loss drugs and sets a $50 per month cost for eligible people with Medicare Part D.
Lists covered and non-covered GLP-1 products for weight loss and specifies formulation limits (e.g., Zepbound® - KwikPen® only).
Defines four required eligibility criteria including Medicare Part D enrollment, absence of certain conditions, not currently receiving a GLP-1 under Medicare drug plan, age ≥18 and meeting BMI requirements.
Coverage Criteria and Eligibility
Medicare GLP-1 Bridge coverage criteria
Coverage is available only for specified GLP-1 products for weight loss and only to beneficiaries meeting ALL program requirements.
ALL of the following
- Medicare Part D drug coverage (standalone or Medicare health plan that includes drug coverage). Not eligible if only enrolled in private fee-for-service, cost contract, or PACE plans.
- Not currently receiving a GLP-1 drug paid for by the beneficiary's Medicare drug plan.
- No diagnosis of Type 2 diabetes, moderate-to-severe sleep apnea, or fatty liver disease.
- Age ≥ 18, prescribed an eligible GLP-1 for weight loss as part of lifestyle changes, and meets BMI eligibility requirements (see BMI criteria node).
ALL of the following
- Foundayo® (tablet) — covered when used to reduce excess body weight and maintain weight reduction.
- Wegovy® (injection or tablet) — covered when used to reduce excess body weight and maintain weight reduction.
- Zepbound® — KwikPen® only (covered).
Excluded products
- Single-dose Zepbound® pen and Zepbound® vials — not covered.
- Mounjaro® — not covered.
- Ozempic® — not covered.
- Rybelsus® — not covered.
ALL of the following
- BMI ≥ 35 — no additional conditions required.
- BMI ≥ 30 — AND at least one of: certain heart failure OR uncontrolled high blood pressure (hypertension) OR chronic kidney disease (stage 3a or above).
- BMI ≥ 27 — AND at least one of: diagnosed pre-diabetes OR history of heart attack or stroke OR peripheral arterial disease (blocked arteries in legs or arms).
ALL of the following
- Participant cost is $50 per month regardless of income; payments are collected outside of Medicare Part D and do not count toward Part D deductible or yearly out-of-pocket limit.
- Program runs from July 1, 2026 through December 31, 2027 (short-term).
- Drugs covered under this program are not eligible for the Medicare Prescription Payment Plan.
ALL of the following
- Talk to your doctor to determine if a GLP-1 drug is appropriate and whether you meet program criteria; visit Medicare.gov/glp1bridge for more information and the approval process.
Appeals criteria
Appeal rights and processes for beneficiaries:
ALL of the following
- If the health service or item is worth at least $1,960 in 2026, you may file an appeal to the Federal District Court within 60 days of the Council denial letter.
- There is no set timeframe for the court to issue a decision after filing.
ALL of the following
- If covered through an SNP, the plan must provide written instructions on how to appeal.
- After you file an appeal, the SNP will review its original decision; if the plan does not decide in your favor, the appeal will be reviewed by an independent organization.
ALL of the following
- Federal court appeal (when permitted) must be filed within 60 days of the Council denial letter.
Covered Products, Codes, and Eligibility Thresholds
| Foundayo® | Foundayo® (tablet) — covered when used to reduce excess body weight and maintain weight reduction |
| Wegovy® | Wegovy® (injection or tablet) — covered when used to reduce excess body weight and maintain weight reduction |
| Zepbound® - KwikPen® | Zepbound® - KwikPen® only — covered when used to reduce excess body weight and maintain weight reduction |
| Zepbound® single-dose pen and vials | Single-dose Zepbound® pen and Zepbound® vials — not covered |
| Mounjaro® | Mounjaro® — not covered |
| Ozempic® | Ozempic® — not covered |
| Rybelsus® | Rybelsus® — not covered |
Provider Verification, Notification, and Escalation Steps
Eligibility verification and beneficiary notification
Confirm all four program eligibility elements before enrollment and notify the beneficiary that fills are outside Part D and cost $50/month (not applied to Part D deductible or out-of-pocket limits). Verify: Medicare Part D drug coverage (standalone or Medicare health plan with drug coverage; exclude only-private-fee-for-service, cost contract, or PACE-only enrollees); beneficiary is not currently receiving a GLP-1 paid by their Medicare drug plan; no diagnosis of Type 2 diabetes, moderate-to-severe sleep apnea, or fatty liver disease; age ≥18 and prescribed an eligible GLP-1 for weight loss and meeting the BMI thresholds. Document verification in the medical record and in any enrollment materials, including the beneficiary's Part D status, current GLP-1 use status, absence of excluded diagnoses, age, prescribed GLP-1 drug, and BMI assessment.
- Confirm Medicare Part D drug coverage (standalone plan or Medicare health plan with drug coverage); exclude beneficiaries whose only Medicare coverage is private fee-for-service, cost contract, or PACE ([[chunk 5]]).
- Confirm the beneficiary is not currently receiving a GLP-1 drug paid for by their Medicare drug plan ([[chunk 5]]).
- Confirm absence of diagnoses: Type 2 diabetes, moderate-to-severe sleep apnea, and fatty liver disease ([[chunk 5]]).
- Confirm age ≥18, prescription for an eligible GLP-1 for weight loss, and that BMI meets program thresholds (see BMI rules): BMI ≥35; BMI ≥30 with specified cardiac/hypertension/CKD criteria; BMI ≥27 with pre-diabetes or atherosclerotic disease history ([[chunk 6]]).
- Inform beneficiary that program fills are outside Medicare Part D, cost $50/month, do not count toward Part D deductible or yearly out-of-pocket limit, and are not eligible for the Medicare Prescription Payment Plan ([[chunk 3]]).
- Record all verifications and beneficiary notification in the medical record and enrollment documentation (document the Part D status, current GLP-1 use, excluded diagnoses, age, prescribed drug, and BMI assessment).
Appeals and escalation after Council denial
If a Council appeal is denied and the disputed service or item meets the 2026 monetary threshold, advise the beneficiary they may file a Federal District Court appeal within 60 days of the Council denial letter. For beneficiaries in Medicare Special Needs Plans (SNPs), ensure the plan provides written appeal instructions and that the plan's internal review and any subsequent independent review processes are followed.
- Federal court appeal available only if the item or service is worth at least $1,960 in 2026; the appeal must be filed within 60 days of the Council denial letter ([[chunk 18]]).
- SNP enrollees: the SNP must provide written instructions on how to appeal; the plan performs an internal review and, if unfavorable, an independent organization reviews the appeal ([[chunk 19]]).
Program Definitions and Notes
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