Historically, Medicare has not covered medications prescribed solely for weight loss. In fact, Medicare is statutorily prohibited from covering these drugs. However, a new demonstration program is designed to improve access to GLP-1 medications for eligible Medicare beneficiaries.
Under current rules, some Medicare Part D and Medicare Advantage plans cover GLP-1 medications for conditions such as diabetes, sleep apnea, and cardiovascular disease—but not for weight loss alone.
Beginning July 1, 2026, a temporary program known as the “Medicare GLP-1 Bridge Program” will provide coverage for certain weight loss medications for beneficiaries who meet eligibility requirements. This program is scheduled to run through December 31, 2027.
Eligible beneficiaries may gain access to FDA-approved GLP-1 medications such as Wegovy and Zepbound (and potentially others). If approved, participants will pay a $50 copayment for each 30-day supply.
It’s important to understand that these copayments will exist outside the standard Medicare Part D benefit structure. As a result, the amounts paid under the Bridge Program will not count toward your Part D deductible or your True Out-of-Pocket (TrOOP) costs. Beneficiaries already receiving a GLP-1 medication for diabetes, cardiovascular disease, or another covered condition will continue under the normal Medicare Part D rules and cost-sharing requirements.
To qualify, you will need to work closely with your physician. Eligibility is based on specific clinical criteria, which may include a Body Mass Index (BMI) of 35 or greater, along with other qualifying health factors. Your physician will submit a prior authorization request to a CMS-designated processor, which will review eligibility and coordinate with the pharmacy if you are approved.
In order to participate in the Bridge Program, you must be enrolled in either a Medicare Part D prescription drug plan or a Medicare Advantage plan that includes prescription drug coverage. Individuals without drug coverage will be ineligible.
Beginning in 2028, the Bridge Program is expected to transition into a longer-term initiative known as the “BALANCE Model.” CMS hopes that most Medicare plans will participate, although beneficiaries enrolled in non-participating plans may not have access to GLP-1 medications for weight loss. As CMS gathers data during the Bridge Program, program details and requirements could evolve.
The long-term impact of these changes on Medicare and Part D plan sponsors is still unclear, but the program has potential to significantly influence prescription drug coverage in the years ahead.
As always, we’re here to help you navigate Medicare and stay informed about changes that may impact your coverage.
Visit us at 2604 Long Prairie Road, Suite 100, Flower Mound, TX, online at Plan Medigap or call 800-750-2407.
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