Medicare Part D
Covered with requirementsWhat you need to qualify
- Age 18 and older
- BMI of 35 or higher
- BMI of 27 or higher with a weight-related condition (pre-diabetes, previous MI, previous stroke, symptomatic PAD, heart failure with preserved ejection fraction, uncontrolled hypertension, and CKD stage 3a or above)
- Diagnosis documented with a code (E66)
- Not being used to treat type 1 diabetes
Qualification pathways
You can qualify through any one of these.
BMI >= 35 (no comorbidity required)
All of:
- Age >= 18 years
- Prescription is for weight reduction and maintenance of weight reduction only (not for any other approved indication)
- Patient has Medicare Part D coverage and has NOT previously received a GLP-1 through their Part D plan
- Patient does NOT have type 2 diabetes, moderate-to-severe sleep apnea, or MASH
- BMI >= 35
BMI >= 30 with qualifying cardiometabolic comorbidity
All of:
- Age >= 18 years
- Prescription is for weight reduction and maintenance of weight reduction only (not for any other approved indication)
- Patient has Medicare Part D coverage and has NOT previously received a GLP-1 through their Part D plan
- Patient does NOT have type 2 diabetes, moderate-to-severe sleep apnea, or MASH
- BMI >= 30
Plus any one of:
- Diagnosis of heart failure with preserved ejection fraction
- Diagnosis of uncontrolled hypertension (systolic BP > 140 mmHg or diastolic BP > 90 mmHg despite concurrent treatment with two antihypertensive medications)
- Diagnosis of chronic kidney disease stage 3a or above
BMI >= 27 with qualifying cardiovascular or metabolic comorbidity
All of:
- Age >= 18 years
- Prescription is for weight reduction and maintenance of weight reduction only (not for any other approved indication)
- Patient has Medicare Part D coverage and has NOT previously received a GLP-1 through their Part D plan
- Patient does NOT have type 2 diabetes, moderate-to-severe sleep apnea, or MASH
- BMI >= 27
Plus any one of:
- Diagnosis of pre-diabetes
- Previous myocardial infarction
- Previous stroke
- Symptomatic peripheral artery disease
Documentation to bring
- Prescriber attestation (under penalty of perjury) that information provided is true and correct
- Obesity diagnosis code (E66 family) on the prescription
- Documentation that patient is >= 18 years of age
- Documentation that the GLP-1 is prescribed to reduce excess body weight and maintain weight reduction only (not for any other approved indication)
- Documentation that patient has not previously received a GLP-1 through their Medicare Part D plan
- Documentation that patient does NOT have type 2 diabetes, moderate-to-severe sleep apnea, or MASH
- Documentation of qualifying BMI (>= 35, or >= 30 with HFpEF/uncontrolled HTN/CKD stage 3a+, or >= 27 with pre-diabetes/prior MI/prior stroke/symptomatic PAD)
- Documentation of qualifying comorbidity if BMI < 35
Quantity limits
- all covered strengths — 28-day or 30-day fills only
Approval and renewal
- To renew, the plan looks for Subsequent fills do not require a new prior authorization unless the patient switches from one covered GLP-1 drug to a different one.
Not covered when
- Patients who have previously received a GLP-1 through their Medicare Part D plan are not eligible
- Patients with type 2 diabetes must submit to their Part D plan (not eligible for Bridge)
- Patients with moderate-to-severe sleep apnea must submit to their Part D plan (not eligible for Bridge)
- Patients with MASH must submit to their Part D plan (not eligible for Bridge)
- Patients enrolled in private fee-for-service plans, section 1876 cost contract plans, section 1833 healthcare prepayment plans, PACE organizations, fallback plans, and religious fraternal benefit plans are not eligible unless also enrolled in a standalone PDP
- Prescription indicated for any approved indication other than weight reduction and maintenance of weight reduction is not eligible
Policy note: This is a short-term CMS demonstration program operating outside of Medicare Part D plan coverage, launching July 1, 2026. The program uses a central processor for PA, claims processing, and pharmacy payment. PA request is pharmacy-initiated (sent to prescriber within 24-72 hours after claim submission). Only 28-day or 30-day fills are covered. A new PA is required only if a patient switches from one covered GLP-1 to another. The program independently verifies patient information (e.g., checks Medicare data for T2DM). Prescriber must not be on the CMS Preclusion List. Wegovy injection and tablets are covered; oral semaglutide (Rybelsus) is not listed as covered. Only Wegovy, Foundayo (oral semaglutide tablets), and Zepbound KwikPen are covered — single-dose Zepbound pen and Zepbound vials are NOT covered.
Policy effective July 1, 2026 · verified July 8, 2026 · source: medicare-glp1-bridge-prescriber-guide.pdf