Program Basics
When does the Medicare GLP-1 Bridge Program begin?
July 1, 2026
This type of Medicare drug coverage is generally needed before a patient might qualify for Bridge.
What is eligible Medicare Part D plan coverage?
This is the minimum age listed in the Bridge clinical criteria.
What is at least 18 years of age?
Before routing to Bridge, prescribers can help expedite the process by asking screening questions about coverage, existing GLP-1 access, diagnosis exclusions, and this.
What are Bridge clinical criteria?
These are the three covered product groups listed in the provided Bridge guidance.
What are Foundayo tablets, Wegovy injection/tablets, and Zepbound KwikPen?
This is the patient copay collected when the prescription is dispensed under Bridge.
What is $50?
This federal agency is expanding access through the Medicare GLP-1 Bridge short-term demonstration.
What is the Centers for Medicare & Medicaid Services, or CMS?
These patients are not eligible for Bridge if they can receive the GLP-1 drug through this coverage source
If a patient has type 2 diabetes, moderate-to-severe sleep apnea, or MASH/fatty liver disease, requests should generally be sent here instead of Bridge.
Under Bridge criteria, the covered prescribing purpose must be to reduce excess body weight and do this.
What is maintain weight reduction?
For a likely Bridge-eligible patient, the prescriber should include this diagnosis code family on the prescription.
What is the E66 family obesity diagnosis code?
This list helps the pharmacy confirm whether a specific product package is included in Medicare GLP-1 Bridge.
What is the covered NDC list?
The $50 copay applies even if the member receives this Medicare assistance.
What is Extra Help / LIS?
The Bridge Program operates outside of this standard plan coverage.
What is Medicare Part D plan coverage?
Patients in PACE organizations, fallback plans, religious fraternal benefit plans, private fee-for-service plans, section 1876 cost contract plans, or section 1833 health care prepayment plans are not eligible unless they also have this.
What is a standalone prescription drug plan, or PDP?
A patient may meet the BMI-only pathway when their BMI is at least this number.
What is maintain weight reduction?
This exact note should be included in the electronic Note field or as a non-electronic annotation.
What is SEND TO BRIDGE FOR WEIGHT MANAGEMENT?
These Zepbound forms are not covered under Medicare GLP-1 Bridge.
What are the single-dose Zepbound pen and Zepbound vials?
Because Bridge operates outside Part D, the $50 copay does not count toward the Part D deductible, annual out-of-pocket maximum, or this payment option.
What is the Medicare Prescription Payment Program?
This entity manages prior authorization, claims processing, and pharmacy payment for the Bridge Program.
What is a central processor?
If a patient has type 2 diabetes, moderate-to-severe sleep apnea, or MASH/fatty liver disease, requests should generally be sent here instead of Bridge.
What is the patient's Part D plan?
A patient with BMI of at least 27 may meet criteria if they have pre-diabetes, previous myocardial infarction, previous stroke, or this vascular condition.
What is chronic kidney disease stage 3a or above?
If the pharmacist does not receive the Bridge routing direction, the claim may be sent here instead.
What is the patient's Part D plan?
Only fills of these durations are covered under Medicare GLP-1 Bridge.
What are 28-day or 30-day fills?
Pharmacies are reimbursed at wholesale acquisition cost less the beneficiary copay, plus sales tax if applicable and this fee.
What is a dispensing fee?
This is the main purpose of the Bridge Program.
What is expanding short-term access to certain GLP-1 medications for eligible people with Medicare Part D?
Although providers and pharmacies can help expedite screening, this party confirms whether a patient is eligible for Medicare GLP-1 Bridge.
Who is CMS / Medicare GLP-1 Bridge?
A patient with BMI of at least 30 may meet criteria if they have heart failure with preserved ejection fraction, uncontrolled hypertension, or this kidney-related condition.
What is chronic kidney disease stage 3a or above?
If no ePA or fax PA request is received within 72 hours, the prescriber should do this.
What is download and submit the CMS fax form?
After the first fill is approved, these do not require a new prior authorization unless the patient switches covered GLP-1 drugs.
What are subsequent fills or refills?
A prescriber believes a patient may be eligible for Bridge, sends the prescription with an E66 code and the Bridge routing note, and the pharmacy receives an initial claim denial. What should happen next in the Bridge process?
What is the claim denial should trigger a prior authorization requirement, the pharmacy should transmit the PA request to the prescriber, and the prescriber should complete the PA so Bridge can issue an approval or denial?