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

Last month marked the introduction of a new Bridge demonstration project by the Trump administration, providing Medicare enrollees, including seniors, with more affordable glucagon-like peptide-1 weight loss medications. However, uncertainties remain over eligibility requirements, the prior authorization process, and program costs.

Running from July this year until December 2027, the Medicare Bridge program is a temporary initiative offering individuals over 65 and certain disabled individuals access to specific glucagon-like peptide-1 agonist weight loss drugs, including Zepbound (tirzepatide), Foundayo (orforglipron), and Wegovy (semaglutide). Eligible participants pay a $50 monthly co-payment, irrespective of their income. The federal government covers a net monthly prescription cost of $245, paid directly to drug manufacturers, after deducting the $50 co-payment.

Semaglutide is available in both injectable and tablet forms, according to Pharmacy Times. Tirzepatide is limited to the KwikPen version, excluding single-dose vials and other pens. Orforglipron is reimbursed for all dosage strengths.

CMS requires that patients must not have type 2 diabetes, moderate-to-severe sleep apnea, or metabolic dysfunction-associated steatohepatitis to qualify for access. These conditions are already covered under the standard outpatient benefit. Additionally, individuals must adhere to strict BMI criteria: a BMI of 35 or higher, or between 27 and 35 with an obesity-related comorbidity.

GLP-1s are utilized for a range of conditions beyond obesity, including type 2 diabetes, sleep apnea, chronic kidney disease, a form of fatty liver disease called MASH, and reducing cardiovascular event risks.

GLP-1s are widely popular and effective, but Medicare coverage for weight loss is legally prohibited. To circumvent this, the Trump administration introduced the Bridge program alongside a five-year pilot called BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth). BALANCE aims to broaden access to GLP-1s for obesity with manufacturer-supported lifestyle aid.

By negotiating reduced net prices for GLP-1 with drugmakers, CMS intended to facilitate Part D plan involvement in BALANCE. However, due to inadequate plan sponsor participation, BALANCE was paused indefinitely. Despite this, CMS proceeded with the Bridge program.

The Bridge program requires a flat $50 monthly co-payment with no exceptions. Patients benefiting from a low-income subsidy in Medicare’s Part D, typically paying little to nothing for medications, receive no reductions. For some seniors and disabled individuals, $50 monthly is a significant expense. Additionally, these co-payments do not count towards deductibles or out-of-pocket maximums.

Despite this, patients and healthcare providers welcome the increased access to obesity medications, especially since statutory rules from 2006 have prevented Medicare from covering weight-loss drugs.

However, as pointed out by a physician in MedPage Today, the program’s eligibility criteria seem inconsistent. According to the Bridge program, if a patient with a BMI of 35 experiences a progression in sleep apnea severity, they are ineligible for GLP-1 access through the initiative. These patients are redirected to their outpatient pharmaceutical benefit plan, which may not offer access, or if it does, could cost hundreds monthly out-of-pocket.

While those seeking access must be enrolled in Part D, the Bridge program operates independently of Part D’s payment and insurance structure. It bypasses the benefit’s claims adjudication. Claims submitted through standard Part D channels instead of the designated central processor are likely to be rejected.

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

Since the demonstration began on July 1, 2026, CMS has yet to release real-world enrollment numbers. However, up to 3.8 million individuals could meet all eligibility requirements.

The Bridge program is set to expire at the end of 2027, raising concerns about the future of the initiative. If not extended by the Trump administration, participants could face discontinuation of medications, potentially leading to weight regain and the return of co-morbidities.

There’s no certainty that the Bridge program will be extended. Its cost could limit its continuation. Spending on GLP-1 drugs for existing covered indications like type 2 diabetes under Medicare and Medicaid has risen sharply. Including coverage for obesity, even at reduced net prices through Bridge, might impose further financial strain on the government.

When the Biden administration proposed adding obesity drug coverage to Part D in 2024, it estimated costs between $25 billion and $35 billion over a decade.

Such substantial figures may have contributed to the reluctance or unwillingness of plan sponsors to engage in the BALANCE model as initially designed.

Notably, CMS documentation hasn’t disclosed potential financial implications for the government from either BALANCE or Bridge. The agency’s decision not to release cost estimates publicly is peculiar, given the potential expense for taxpayers. Is the agency hesitant to be incorrect, or is CMS relying on the Congressional Budget Office to provide the numbers?

The CBO estimates that if every eligible beneficiary enrolled in the Bridge initiative, taxpayer spending could exceed $30 billion annually. While it’s unlikely that such a large number will participate, even if 20% do, the cost would be approximately $6 billion annually, potentially limiting the government’s ability to finance other healthcare services.