For the first time in the program’s history, Medicare is covering weight-loss drugs, and the price tag looks almost too good to pass up.Beginning July 1, eligible Part D enrollees can access medications including Wegovy, Foundayo, and the Zepbound KwikPen for a flat $50 monthly copay through a temporary federal demonstration called the Medicare GLP-1 (glucagon-like peptide-1) Bridge.That is a massive discount compared to the retail price of these drugs, which can exceed $1,000 per month without insurance coverage. It arrives at a moment when roughly 56% of GLP-1 users say affordability is a significant challenge, a poll from KFF, the health policy research organization, found.But this is not traditional Part D coverage, and the distinction creates financial consequences that could blindside enrollees who assume the program works like every other Medicare prescription benefit they have used.How the GLP-1 Bridge $50 copay falls outside Part D’s safety netThe GLP-1 Bridge operates entirely outside the Part D benefit structure, and that separation has three practical effects that enrollees need to understand before filling a prescription.The $50 monthly copay does not count toward the Part D deductible or the $2,100 annual out-of-pocket spending cap for 2026, which rises to $2,400 in 2027, the Centers for Medicare & Medicaid Services confirmed.Enrollees who receive the Low-Income Subsidy, also known as Extra Help, cannot apply that cost-sharing assistance to Bridge program copays, a KFF analysis noted.The copay is not eligible for the Medicare Prescription Payment Plan, which lets beneficiaries spread out-of-pocket drug costs throughout the calendar year.”Not only do the costs not count toward your out-of-pocket cap, your deductible or anything like that, if there is a problem, you also need to go to Medicare. You do not go to your plan,” Leigh Purvis, prescription drug policy principal at AARP’s Public Policy Institute, said.For a beneficiary who stays on the medication for the full 18-month demonstration, total out-of-pocket spending on the Bridge copay alone would reach $900, the American Action Forum calculated.Why low-income seniors face steepest barrier to GLP-1 accessThe Extra Help exclusion carries outsized consequences because the program’s target population skews toward older adults living on fixed incomes who rely on prescription cost-sharing subsidies.About one in four Medicare beneficiaries had an income below $24,600 in 2024, KFF reported, and Low-Income Subsidy enrollees pay no more than $5.10 for a generic prescription and $12.65 for a brand-name prescription in 2026.More Medicare/Medicaid:IRMAA hits retirees two years after property saleNew Medicare GLP-1 pilot program could lower drug costsMedicare’s 2033 funding crisis: What retirees should do right nowA recurring $50 monthly charge on top of existing prescription spending represents a meaningful burden for that group, and because it sits outside Part D’s benefit architecture, it does not bring them closer to the annual cap that shields against catastrophic drug costs.Rachel Schmidt, a research professor at Georgetown University’s McCourt School of Public Policy, told CNBC that the $50 monthly copay for GLP-1s “will not count toward a patient’s Part D deductible, or the $2,100 annual out-of-pocket cap on prescription drug costs.” For a beneficiary on the medication for a single calendar year of the demonstration, that amounts to $600 in out-of-pocket spending that does not count toward Part D’s catastrophic coverage protections.
Low-income Medicare beneficiaries face higher barriers as new GLP-1 copays increase costs without counting toward annual out-of-pocket limits.SimpleImages/Getty Images
Eligibility requirements narrow pool of potential GLP-1 Bridge enrolleesNot every Medicare enrollee seeking a GLP-1 prescription for weight management can participate, and the clinical criteria limit eligibility to specific health profiles. Enrollees must be in an eligible Part D plan and meet one of three body mass index thresholds paired with specific clinical conditions, CMS confirmed.Beneficiaries with a BMI of 35 or higher qualify without additional clinical requirements, while those with a BMI of 30 or higher must also have chronic kidney disease at stage 3a or above, heart failure with preserved ejection fraction, or uncontrolled hypertension despite treatment with two medications.Juliette Cubanski, director of the Program on Medicare Policy at KFF, says Medicare’s short-term initiative faces an uncertain future, CNBC reported.It’s good news that Medicare is rolling out this program, but it is temporary, so it’s really not clear at this point what happens after the end of the 18-month program duration.A third tier covers enrollees with a BMI of 27 or higher who have a diagnosis of prediabetes, a previous heart attack or stroke, or symptomatic peripheral artery disease.CMS specifically disqualifies beneficiaries diagnosed with type 2 diabetes, moderate to severe obstructive sleep apnea, or noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH), and also excludes anyone already filling a GLP-1 prescription under their Part D plan in 2026.How to navigate GLP-1 Bridge enrollment and avoid common pitfallsThe Bridge program requires a prior authorization from the prescribing provider, and CMS is targeting a 72-hour turnaround for initial decisions, a CMS official confirmed during a recent webinar for pharmacists.CMS guidance for beneficiaries emphasizes three practical checks before filling a Bridge prescription. Beneficiaries should confirm the Part D plan type is eligible, that the provider writes the prescription specifically for weight management rather than for a condition already covered under Part D, and that the pharmacy submits the claim to the Bridge central processor rather than to the beneficiary’s regular Part D plan.Beneficiaries should know that the copay does not accrue toward Part D’s out-of-pocket cap or deductible.”Fortunately, once the prescriber completes prior authorization for the drug, the program uses routine pharmacy processes,” said Lisa Schwartz, senior director of professional affairs at the National Community Pharmacists Association. “We would encourage patients to try to have a little extra patience with their provider and the pharmacy the first month or so.”If a Bridge prior authorization is denied, CMS says there is no formal Bridge appeals process, though the prescriber can resubmit with corrected or additional documentation, and beneficiaries can call 1-800-MEDICARE for help.Related: Can Medicare Help You Get GLP-1s? Requirements You Need to Know