CMS Launches Medicare GLP-1 Bridge for Certain Medicare Part D Beneficiaries

Action: On July 1, the Centers for Medicare & Medicaid Services (CMS) launched Medicare GLP-1 Bridge,¹ a demonstration program that will provide eligible Medicare beneficiaries access to certain GLP-1 medications for weight management at a $50 monthly copay through December 31, 2027. The program is separate from the standard Medicare Part D benefit.

Trusted Insights for What’s Ahead^®

• GLP-1 drugs have demonstrated clinical value but remain expensive, raising broader questions about program costs and long-term use and outcomes.² Most private plans do not cover use of GLP-1 drugs for weight loss; those that do generally include strict prior authorization and other requirements (such as high Body Mass Index scores and comorbidities and proof of weight loss).³
• This temporary program expands access to GLP-1 medications for beneficiaries who seek treatment to reduce excess body weight or maintain weight reduction but would not otherwise have access to these drugs through Part D. Eligible products currently include Foundayo®, Wegovy®, and Zepbound® KwikPen®.
• Beneficiaries will pay a fixed $50 copay that does not count toward Part D out-of-pocket costs. CMS also states that participating manufacturers will provide eligible GLP-1 drugs at a net (and presumably negotiated) price of $245 per monthly supply, meaning Medicare will cover over 80% of the cost.
• Eligibility is targeted. Beneficiaries must meet clinical criteria based on body mass index (BMI) and, in some cases, qualifying conditions such as cardiovascular disease, kidney disease, prediabetes, prior stroke, or uncontrolled hypertension. An analysis based on 2023 claims data estimates that nearly 4 million Part D beneficiaries could be eligible.⁴
• Drugs used for weight loss, including anti-obesity medications, are generally excluded from Medicare. However, GLP-1 drugs are covered for Medicare when prescribed for diabetes, cardiovascular risk reduction, obstructive sleep apnea, or liver disease. The demonstration permits CMS to gather utilization data to inform future policy, including other innovation models being tested to pair negotiated GLP-1 access with nutrition and physical activity supports.⁵
• CMS hopes greater use of these drugs for weight management will lead to savings in the program over time as beneficiaries are healthier.
• CMS is setting guardrails to prevent the program from becoming a substitute for Part D coverage. Beneficiaries with Part D-coverable indications are excluded, and Part D plans must maintain normal coverage, formulary exception, and appeal processes. CMS will monitor Part D and Bridge data for inappropriate cost shifting, including plan practices that deny, limit, or redirect coverage to avoid Part D responsibility.
• What this means for business:
  • GLP-1s are a major health benefits issue across public and private markets. Survey data of employers shows concern that GLP-1s are contributing to rising health care costs.⁶ As public programs test new approaches to GLP-1 access and pricing, the impact will likely shift to private plans as well, particularly if the demonstration project succeeds and becomes the basis for new CMS policy.