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Part C Medicare Advantage Part D Prescription Drug

About the Medicare GLP-1 Bridge Program

Beginning July 1, 2026, a new federal initiative called the Medicare GLP-1 Bridge Program will allow individuals enrolled in a Part D plan to access certain highly sought-after weight-loss drugs for a flat copay of $50 a month.

According to the Centers for Medicare & Medicaid Services (CMS), this temporary demonstration program will run through December 31, 2027. The goal is to make these treatments more affordable while the government evaluates long-term coverage models.

Here are the essential details you need to know about who qualifies, what is covered, and how to get started.

1. Who Is Eligible?

You must be enrolled in a standalone Medicare Part D prescription drug plan or a Medicare Advantage plan that includes drug coverage. (This excludes the MA-Only plans that do not include drug coverage.) However, because this is a medical demonstration, you cannot simply request the $50 rate at the pharmacy counter. Your doctor must submit a Prior Authorization showing you meet specific medical categories based on your Body Mass Index (BMI):

  • Tier 1: A BMI of 35 or higher (no other health conditions required).

  • Tier 2: A BMI of 30 to 34.9 plus at least one of these conditions: heart failure, uncontrolled high blood pressure, or chronic kidney disease.

  • Tier 3: A BMI of 27 to 29.9 plus at least one of these conditions: pre-diabetes, a history of a heart attack, a history of a stroke, or peripheral artery disease.

Note: The program specifically excludes patients who have Type 2 diabetes, moderate-to-severe sleep apnea, or fatty liver disease, as those individuals are typically already eligible for GLP-1 coverage directly through standard Part D plans.

2. Which Medications Are Included?

The $50 monthly price is the result of a negotiated agreement between the federal government and certain drug manufacturers. The program strictly covers specific brand-name formulations prescribed specifically for weight management:

  • Wegovy® (both the standard injectable and the newer oral tablet versions).

  • Zepbound® (strictly limited to the KwikPen® formulation; standard single-dose vials or pens are not covered).

  • Foundayo® (Eli Lilly’s newly approved oral pill).

Medications like Ozempic® and Mounjaro® are not part of this $50 weight-loss program because they are FDA-approved to treat Type 2 diabetes and are already handled under standard Medicare Part D formularies.

3. The “Fine Print” Seniors Need to Know

Because the Bridge program operates entirely outside of the traditional Medicare Part D design, there are a few unique rules to keep in mind:

  • Out-of-Pocket Limits: The $50 monthly copay does not count toward your standard Part D deductible or your annual $2,100 out-of-pocket maximum.

  • Extra Help: Because the program includes a flat $50 copay for everyone who qualifies, the federal Low Income Subsidy (Extra Help) and New York State EPIC cost-sharing protections do not apply to this program.

  • Supply Limits: The program will only cover 28-day or 30-day supplies at a time.

How to Take Action

You do not need to sign up for a new insurance plan to participate. If you think you meet the BMI and health criteria, schedule an appointment with your doctor. Your physician will need to write the prescription with specific instructions for the Bridge program, and they will submit the required medical paperwork directly to the program’s central processor (managed by Humana) to approve your $50 rate. You may want to provide your provider with a copy of the CMS Prescriber Guide and the CMS Pharmacy Operational Framework. for their review.

Click below and watch our June 9 “Ask the Experts” interview where Chris, Kate and I answer some questions about the GLP-1 Bridge Program:

An interesting article comparing several GLP-1 medications: https://www.health.com/glp-1s-weight-loss-8674445

 

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Medicare Part D Prescription Drug

The New Law and Medicare Part D

The US House and Senate has passed a bill (H.R. 5376 titled Inflation Reduction Act of 2022) which includes some important changes to the Medicare Part D prescription drug coverage.

Some of these changes take effect next year and others over the next several years. I have looked over the text, studied several analysis and have summarized below the 4 changes most likely to Medicare beneficiaries:

  1. Insulin – Effective 2023
  2. Adult Vaccines – Effective 2023
  3. Cap on Out of Pocket Drug Costs – Effective in 2024 and 2025
  4. Medicare to Negotiate Part D and Part B Drug Prices – Effective 2026

Please note: If you are receiving Part D financial assistance through state Medicaid or the Social Security Extra Help program, your benefits may already exceed what is becoming effective in this new bill. Also, if your medications are covered through your VA benefits, you may want to compare these new benefits to what VA covers and compare your options in the years ahead.

1. Insulin – Effective 2023 Beginning in 2023, for Medicare Part D beneficiaries who need insulin, monthly out-of-pocket costs will be capped at $35, and starting in 2026, the cap would be $35 or 25% of the negotiated price if that is lower. And insulin products will no longer subject to a Part D deductible.

2. Adult Vaccines – Effective 2023
Beginning in 2023, Medicare Part D cost-sharing will be eliminated for adult vaccines that are recommended by the Advisory Committee on Immunization Practices. For most clients, the most significant change will be the new $0 Part D copay for the two shot Shingles vaccine, previously covered through Part D however frequently subject to a deductible and higher Tier copay.

3. Cap on Out of Pocket Drug Costs – Effective in 2024 and 2025
For clients with drug costs placing them in the “Coverage Gap” (aka Donut Hole) and Catastrophic Coverage Phase, this change will be very welcomed although phased in over time.

In 2024, that 5% coinsurance payment that now kicks in after someone reaches the catastrophic drug spending level in Medicare will end. As you may imagine, 5% on some of those expensive drugs that cost thousands monthly can be a lot of money. That ends in 2024.

And in 2025 your Medicare Part D out-of-pocket spending will be capped at $2,000 a year, increased to $2,100 in 2026.

4. Medicare to Negotiate Part D and Part B Drug Prices
CMS (Centers for Medicare & Medicaid Services) will be authorized and required to negotiate maximum prices for brand-name drugs that do not have other generic equivalents and that account for the greatest Medicare spending.

There is not yet an official, publicly available list of drugs that Medicare plans to target for negotiations. However Kaiser Family Foundation reports how just a handful of drugs represent the lion’s share of Medicare drug costs. Some likely candidates, based on how much Medicare spent on them in 2020: Eliquis, Xarelto and Januvia.

Today, those brand name drugs that do not have generic equivalents and represent the greatest cost are typically listed as Tier 4 or Tier 5 specialty medications under Medicare Part D coverage.

CMS will begin by negotiating the prices of 10 drugs in 2026, 15 drugs in 2027 and 2028, and 20 drugs in 2029 and each year thereafter. The negotiations would apply first to drugs people get at the pharmacy (Part D), but in the later two years, drugs administered in doctors’ offices (Part B) could also be covered.

If you have any questions or would like for me to review with you your plan benefits please schedule a telephone or Zoom conference convenient for you and direct to my calendar, call us at (518) 346-2115 or send a note to one of our licensed and carrier certified agents closest to you:

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Case Studies Medicare supplement

A conversation: Focus the fight against cancer instead of the HMO

Medicare Supplement Plan

In this nearly 16 minute conversation Greensboro North Carolina residents, Bob and Signe Foxworth, talk about their frustration and anxiety of trying, unsuccesfully, to obtain HMO approval for Bob’s preferred out of network prostate cancer treatment. Listen as Bob and Signe explain how peace of mind came when Dan counseled them to revert to Original Medicare and enroll in Medicare Supplement Plan N.
Signe: “As I recall, it was tremendous anxiety at the time. Because not being able to get the treatment sooner rather than later could have had fatal consequences … We had more anxiety fighting the (HMO) insurance company than we did about his illness… We were kind of at our wits end.”
Bob: “I got $20,000 worth of treatment for $20 … Everything was covered.”
Signe: “In this whole thing, the most precious thing is that peace of mind knowing that you are covered. Yes, you strain a little on your monthly budget But things happen unexpectedly and you are covered. It’s really beautiful.”

For a personal consultation regarding your Medicare choices, call Dan at (518) 346-2115