Prescriber quick reference: the GLP-1 Bridge PA
Short answer: For clinicians: the Medicare GLP-1 Bridge (July 2026 – December 2027) covers Wegovy, Zepbound (KwikPen only), and Foundayo at a $50 patient copay, outside the Part D benefit, via prior authorization to a central processor administered by Humana. Eligibility is BMI-tiered with specific comorbidity requirements, and three diagnoses reroute patients to standard Part D instead.
Program facts last verified against CMS: July 21, 2026
PA criteria at a glance
Document one: BMI ≥35 alone; BMI ≥30 with stage ≥3a CKD, heart failure, or uncontrolled hypertension; or BMI ≥27 with prediabetes, prior MI, prior stroke, or symptomatic PAD. Confirm Part D enrollment (any plan; no plan opt-in involved). Exclusions that route to standard Part D coverage under existing indications: type 2 diabetes, moderate-to-severe OSA, and noncirrhotic MASH with fibrosis — for those patients, submit through the patient's drug plan under the applicable indication instead.
Prescribing specifics worth flagging: Zepbound must be prescribed as KwikPen for program processing (vials and single-dose pens reject); the $50 copay sits outside Part D, so it neither accrues TrOOP nor accepts LIS; and the demonstration currently ends December 31, 2027 — worth factoring into duration-of-therapy conversations.
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Common questions
Where does the PA go?
To the program's central processor, administered by Humana — not to the patient's Part D plan. CMS's provider-facing program pages carry current submission specifics.
Does mild OSA exclude a patient?
No — only moderate-to-severe OSA triggers the Part D routing. Mild OSA patients remain Bridge-eligible under the normal tiers.
A patient qualifies under multiple tiers. Which do I document?
Any single satisfied criterion suffices; documenting the most robust one (e.g., BMI ≥35 alone) minimizes resubmission risk.
Related
Program-fact sources: CMS — Medicare GLP-1 Bridge · KFF