A Guide to the Medicare Bridge Program

On July 1, the Medicare Bridge Program begins accepting prescriptions for GLP 1 medications at a cost of $50 per month.  Here at Rainier Medical, we are excited to fully utilize this groundbreaking opportunity to make a huge impact on the health of older Americans.  Please read this guide and pass it on to friends and family so we can get the word out on what the program is and how to use it! Here are the most common questions and answers.

What is the program?

The Bridge program is a short term program lasting from July 1, 2026 through December 31, 2027 to obtain more information for the BALANCE program. The purpose is to lower the cost of GLP 1 medications for weight management who do not have coverage through their Medicare Part D plan. It is NOT for people who do meet the criteria for coverage currently for non-weight management indications through Part D (e.g. established cardiovascular disease, obstructive sleep apnea, metabolic liver disease, Type 2 Diabetes Mellitus). 

Who is included in the program?

Medicare Part D beneficiaries 18 years of age and older enrolled in eligible plan types are included in this program. Common examples include standalone prescription drug plans and Medicare Advantage plans. For complete information, read here. 

What medications are included?

All GLP 1 medications FDA approved for weight management are included. These are Wegovy tablets and injections, Zepbound kwikpen (not auto injector or vials), and Foundayo tablets. 

What are the medical eligibility criteria?

The first medical criteria are related to ensuring a patient does NOT have coverage currently through Medicare part D.  Then, there are 3 categories in which one can qualify for the Bridge program if they are not eligible through Part D. 

  Part D Eligibility: If you have any of these, you may have coverage through part D and are not eligible through the Bridge Program: 

1. Established cardiovascular disease : prior heart attack or stroke, severe peripheral arterial disease

2. Moderate to severe Obstructive Sleep apnea

3. Liver fibrosis stage F2 or F3 due to metabolic associated liver disease

4. Type 2 diabetes mellitus

Bridge Program: if you do NOT have any of the above, and DO have one of these, you may be eligible:  *Note: the BMI is based on the starting BMI prior to treatment with a GLP 1. So, if you have been paying out of pocket and are now below this BMI, your BMI at the time of GLP1 initiation is used.

1. BMI greater than or equal to 35, or

2. BMI greater than or equal to 30 plus:  (A) heart failure with preserved ejection fraction, (B) uncontrolled hypertension (defined as systolic blood pressure above 140 mm Hg or diastolic blood pressure above 90 mm Hg, despite concurrent treatment with two antihypertensive medications), or (C) chronic kidney disease, or

3. BMI greater than or equal to 27 plus one or more of the following: (A) pre-diabetes (as defined by American Diabetes Association guidelines), (B) previous myocardial infarction, (C) previous stroke, or (D) symptomatic peripheral artery disease.

Be sure to have your height measured! Many people lose height with aging and oftentimes a historical height is used to calculate BMI. Of note, it is not clear to me how the last criteria differs from that of Part D.  

How do I apply?

To apply, your provider writes a prescription using an appropriate diagnosis, for an appropriate medication, to an appropriate pharmacy, with a special notation.  It is then checked with a special code to see if the member is eligible through Part D.  If they are, a prior authorization request is sent to the provider for the Part D program using the appropriate different diagnosis.. If they are not, a different prior authorization form is sent to the prescribing provider with a 3 page form to complete and attest to based on the criteria above.  

What is the cost and how does it compare to Part D?

If approved, the cost is $50 a month for whichever drug at whichever dose is prescribed.  This is nice because you and your prescriber can select the best medication and the best dose medically. Currently, out of pocket costs vary significantly depending on the medication, formulation, and dose, so oftentimes that is factored into the selection. Even people with commercial coverage tend to have the medication dictated by their plan, so this is very nice that once you are eligible, you and your provider select the medication without required step therapy!

Of note, the annual cost for GLP 1 medication under the Bridge program is $600 a year. Compare that to someone who has coverage under Part D and does not take any other brand name medications. Their cost is $2100 a year. So, people who have coverage under Part D may pay significantly more than people who currently do not have coverage. But, the program does not allow people to choose to use the Bridge program if they are eligible under the Part D program. But, as a prescriber, sometimes when I see a patient now, we will do additional testing to meet eligibility criteria for Part D.  Now, we may not do that testing if it is of no medical benefit to the patient.  For example, if someone has elevated liver enzymes now but has not had a liver elastography, we may not choose to do the test because it does not provide any medical benefit to the patient if a GLP 1 medication is going to be used and weight reduction is going to be achieved even without it.  Or, if someone has loud snoring but has never had a sleep study, we just use Zepbound rather than doing a sleep study and then reassess snoring after 6 months, unless it seems the sleep apnea is so severe that they need a test now, such as if they have heart arrhythmias, uncontrolled high blood pressure, are drowsy during the day, or other indication. This is a change, because for the last 18 months, many people were getting liver elastography tests and sleep studies for the sole purpose of meeting Part D coverage. Of course, at times a CPAP is also needed in addition to Zepbound, and sometimes a person needs to see GI if their liver disease appears severe or does not improve with a GLP 1. 

Summary

Overall, the Bridge program is very exciting because it seeks to offer a much lower cost option for the GLP 1 medication of the patient’s choice for the indication of weight management.  It also has what seem to be very reasonable medical criteria that appropriately stratifies excess weight with excess health risk.  Some pitfalls are a complex application process and the fact that the cost for Part D coverage is 3.5 times higher unless you are on other brand name drugs. The process may be even more of a burden on primary care providers, especially since it is different from the usual already cumbersome process. Hopefully, they will see that the added administrative costs to the system is not worth the complexity and to just let the licensed provider and the patient decide! Hopefully, this will offer an option for many people currently on non FDA approved products to transition to a brand name medication with appropriate medical guidance and monitoring. There are additional risks noted especially for people over the age of 75. So, whether you or someone you know is just accessing these for the first time, lowering costs which can help make sure they can stay on them as long as needed, or switching from a compounded or experimental medication, let's get the work out and utilitze the Bridge program!

Take Back Your Medicare Bridge Benefits,

Valerie Hope-Slocum Sutherland, MD