Medicare’s GLP-1 Bridge Demo Offers Access, But Isn’t Straightforward

For some seniors and others enrolled in Medicare who want more affordable access to popular glucagon-like peptide-1 weight loss medications, they’re getting it as of last month for the first time through a so-called Bridge demonstration project initiated by the Trump administration. But questions linger with respect to eligibility criteria, the prior authorization process and cost of the program.

The Medicare Bridge program is a temporary demonstration project that runs from July of this year through December 2027 that provides people over 65 and certain disabled individuals access to select glucagon-like peptide-1 agonist weight loss medications, including Zepbound (tirzepatide), Foundayo (orforglipron) and Wegovy (semaglutide). If eligible, beneficiaries pay a flat co-payment of $50 per month, regardless of income. For the federal government, the net monthly cost per prescription is $245, to be paid directly to drug manufacturers, minus the $50 co-payment.

According to Pharmacy Times, semaglutide is covered in injectable and tablet form. Tirzepatide is covered only as the KwikPen. Single-dose vials and other pens are explicitly excluded. Orforglipron is reimbursed for all dosage strengths.

To qualify for access, CMS explicitly mandates that a patient must not have type 2 diabetes, moderate-to-severe sleep apnea, or metabolic dysfunction-associated steatohepatitis. The justification given is that these conditions are already technically “covered” indications under the standard outpatient benefit. Furthermore, individuals must meet strict body mass index rules, namely a BMI of 35 or higher, or between 27 and 35 with an obesity-related comorbidity.

Besides obesity, GLP-1s are used to treat a wide range of conditions, including type 2 diabetes, obesity, sleep apnea, chronic kidney disease, a form of fatty liver disease called MASH and risk reduction related to cardiovascular events.

While GLP-1s are popular and have demonstrated effectiveness, they’re prohibited by law from coverage by Medicare for weight loss alone. To bypass this statutory restriction, the Trump administration established the Bridge program coupled with a five-year pilot called BALANCE, which stands for Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth. BALANCE is a voluntary initiative aimed at expanding access to GLP-1s for obesity while providing manufacturer-supported lifestyle support.

By negotiating lower net prices for GLP-1 with drug manufacturers, CMS theoretically created a favorable condition for Part D plan participation in BALANCE. But CMS had to indefinitely pause the demonstration project owing to insufficient plan sponsor participation (did not reach an 80% threshold). Though BALANCE has been put on hold, CMS has moved ahead with Bridge.

The Bridge co-payment is flat at $50 a month with no exceptions. Patients with a low-income subsidy in Medicare’s outpatient pharmaceutical benefit called Part D, who are used to paying little or nothing out-of-pocket for their medications, get no reduction. For some seniors and disabled folks like those with a LIS, $50 a month is still a big expense. Furthermore, $50 co-payments do not count towards a beneficiary’s deductible or out-of-pocket maximum.

Still, for patients and healthcare providers alike, easing access to obesity drugs is a welcome move, particularly in light of the fact that statutory rules written in 2006 have long precluded Medicare from covering weight-loss medications.

But. as a physician writes in MedPage Today, the program’s eligibility rules appear disjointed. The Bridge program rules dictate that if a patient has a BMI of 35, but their sleep apnea crosses the threshold from mild to moderate, they are disqualified from gaining access to a GLP-1 through the Bridge initiative. Patients are then redirected back to the plan that manages their outpatient pharmaceutical benefit, which may or may not provide access, and if it does the charges could be hundreds of dollars per month out-of-pocket.

Although individuals seeking access must be enrolled in Part D, the Bridge program operates completely outside Part D ‘s payment and insurance structure. It therefore bypasses the benefit’s claims adjudication. In fact, if claims are submitted through standard Part D channels rather than the designated central processor, they will likely lead to coverage rejections.

Prescribers must submit a beneficiary’s prescription and prior authorization request directly to Bridge’s central processor managed by the Centers for Medicare and Medicaid Services rather than the recipient’s drug plan. It can take up to several days to process these requests, which apply to all Bridge prescriptions.

Given that the demonstration only began Jul. 1, 2026, CMS has not yet released real-world enrollment numbers. But up to 3.8 million could meet all eligibility criteria.

With the Bridge program scheduled to expire at the end of 2027, a question looms regarding what will happen when the initiative terminates. If the Trump administration doesn’t extend it, this could lead to people stopping their medications. In turn, this would likely result in weight gain and the return of co-morbidities.

There are no guarantees that Bridge will be extended. The program’s cost may prove to be a limiting factor. Spending on GLP-1 drugs for currently covered indications such as type 2 diabetes under Medicare and Medicaid has increased substantially in a relatively short period of time. Adding coverage of GLP-1s for obesity, even at the lower net prices CMS will pay for these medications under Bridge, could add another financial liability for the government that may be called into question.

When the Biden administration first proposed adding coverage of drugs for obesity alone to Part D in 2024, it estimated the cost at between $25 billion and $35 billion over 10 years.

Such large numbers could have been a driving factor in the reluctance or unwillingness of plan sponsors to participate in the BALANCE model as it was originally designed.

Curiously, CMS documentation hasn’t included potential financial implications for the government from either BALANCE or Bridge. The agency’s decision not to publicly release cost estimates is especially odd given how expensive this could be for taxpayers who foot the bill. Is the agency afraid to be wrong? Or is CMS deferring to the Congressional Budget Office which has crunched the numbers?

The CBO has estimated that if every eligible beneficiary enrolled in the Bridge initiative annual taxpayer spending on the program could exceed $30 billion. Of course, it’s not likely that so many folks will actually take the medications. But suppose that 20% do, the cost would be roughly $6 billion annually, a large number that could crowd out the ability of government to fund other healthcare items.