06/16/2026
You may have heard that Medicare coverage for GLP-1 meds will change starting July 1st. I anticipate that we will be flooded with inquiries from patients. So I did a little research and compiled some info here. I’m hoping this will allow you all to directly answer some of the patients’ questions, thus saving everyone a little time and energy.
It’s called the Medicare GLP-1 Bridge program. Effective 7/1/26-12/31/27.
$50/month co-pay for Wegovy (pen and pill), Zepbound (Kwikpen only) and Foundayo.
We have no clue what will happen after Dec 2027.
They WILL NOT accept any requests prior to July 1st.
This does not go through their Part D plan. So, the cost of this does NOT count towards the yearly Part D maximum. Humana will be handling all the processing. Prior authorizations will be submitted through CoverMyMeds or via fax
The coverage is only for weight loss purposes! No sleep apnea, heart disease or fatty liver diagnosis as they expect these to go through the patient’s part D plan.
For the prescriptions, we need to use obesity codes (E66) and indicate “SEND TO BRIDGE FOR WEIGHT MANAGEMENT” on the note to pharmacy field.
Only one month's supply will be dispensed. They will not allow a 3 month supply of medication.
Note the weight criteria is different from the FDA criteria. For patients already on a GLP-1, we need to submit the BMI at the time they started the medication, not their current BMI.
BMI >35
BMI >30 plus one of the following:
(A) heart failure with preserved ejection fraction, (B) uncontrolled hypertension (defined as SBP > 140 mm Hg or DBP > 90 mm Hg, despite concurrent treatment with two antihypertensive medications), or (C) chronic kidney disease stage 3a or above
BMI >27 plus one of the following:
(A) pre-diabetes, (B) previous myocardial infarction, (C) previous stroke, or (D) symptomatic peripheral artery disease.
It looks like pre-diabetes and CKD 3a will encompass the most patients for those who don’t start with a BMI >35. FYI, for the clinical staff doing the prior auth, any documented GFR
Centers for Medicare & Medicaid Services (CMS) announced the Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) Model and a separate short-term demonstration (now called the “Medicare GLP-1 Bridge”)
