Medicare (Part D + GLP-1 Bridge)
Federal program · updated August 8, 2026
Coverage right now
- Foundayo™ (orforglipron) Covered
- Ozempic® (semaglutide) Covered
- Saxenda® (liraglutide) Excluded
- Wegovy® (semaglutide injection) Covered
- Wegovy® tablets (oral semaglutide) Covered
- Zepbound® (tirzepatide) Covered
Weight-loss-only GLP-1 use remains statutorily EXCLUDED from Part D (2003 MMA). The temporary Medicare GLP-1 Bridge (July 1, 2026 - Dec 31, 2027) fills the gap at a flat $50/month for Foundayo, Wegovy (all forms), and Zepbound KwikPen — running entirely outside the Part D plan. Diabetes (Ozempic/Mounjaro) and secondary indications (Zepbound-OSA, Wegovy-CV) route through standard Part D with PA.
Drug status
| Drug | Status | Detail | Confidence |
|---|---|---|---|
| Zepbound® (tirzepatide) | Covered from Jul 1, 2026 to Dec 31, 2027 | Bridge: KwikPen ONLY, $50/month flat. Vials and single-dose pens NOT covered. Part D proper: OSA indication coverable plan-by-plan. source | high |
| Wegovy® (semaglutide injection) | Covered from Jul 1, 2026 to Dec 31, 2027 | Bridge: all formulations, $50/month. Part D proper: CV-risk-reduction indication coverable plan-by-plan. source | high |
| Wegovy® tablets (oral semaglutide) | Covered from Jul 1, 2026 to Dec 31, 2027 | Bridge: covered, $50/month. source | high |
| Foundayo™ (orforglipron) | Covered from Jul 1, 2026 to Dec 31, 2027 | Bridge: all formulations, $50/month. source | high |
| Ozempic® (semaglutide) | Covered | Part D for T2D under normal formulary rules (PA confirms diagnosis). NOT in the Bridge. source | high |
| Saxenda® (liraglutide) | Excluded | Not in the Bridge; Part D weight-loss exclusion applies. source | high |
What preferred, covered and exception only mean
- Preferred
- On the formulary at the plan's best tier for this class. Usually still needs prior authorization — preferred is not the same as automatic.
- Covered
- On the formulary, but not the plan's first choice for this class. Often a higher copay tier than a preferred drug.
- Non preferred
- On the formulary at a disadvantaged tier, or reachable only after trying a preferred drug first.
- Exception only
- Not routinely covered. Obtainable only through a formulary-exception request that meets the plan's published criteria.
- Excluded
- Not on the formulary at all. A benefit exclusion is a different fight from a PA denial and is appealed differently.
- Varies
- The payer's own documents differ by plan or line of business, so a single answer here would be wrong.
- Unknown
- Not yet verified against a primary document. Recorded as absent rather than guessed.
- N/A
- Not applicable to this payer.
Prior authorization criteria
high- PA required
- Bridge: prescriber attestation via PA (submitted after the pharmacy claim triggers the request — prescriber must wait for the pharmacy-initiated request), under penalty of perjury.
- Initial BMI
- Category 1: BMI >= 35 (no comorbidity). Category 2: BMI 30-34.9 + heart failure with preserved EF, uncontrolled hypertension (SBP>140 or DBP>90 despite two agents), or CKD >= 3a. Category 3: BMI 27-29.9 + pre-diabetes, prior MI, prior stroke, or symptomatic PAD.
- Comorbidities
- Per categories above.
- Lifestyle requirement
- 'Current and ongoing lifestyle modification' attestation — no program documentation.
- Initial authorization
- Bridge PAs valid through Dec 31, 2027.
- Reauthorization
- None during the Bridge window.
- Step therapy
- None.
- Quantity limits
- One-month supplies; $50 per fill.
Primary criteria document:cms.gov
Exceptions and appeals
- Appeal deadline
- 65 days
- Deadline detail
- 65 calendar days from the coverage-determination notice — changed from 60 effective Jan 1, 2026. Most consumer guides still say 60.
- Exception route
- Part D proper: coverage determination request to your plan (formulary/tiering exceptions need the prescriber's supporting statement — the clock starts when the plan receives it).
- Turnaround
- Coverage determination: 72h standard / 24h expedited. Redetermination: 7 days standard / 72h expedited.
- Where
- Your Part D plan, per the determination notice. Five levels: plan -> IRE -> ALJ (AIC >= $200 in 2026) -> Council -> federal court (>= $1,960).
Source:cms.gov
Dated changes
- Jul 1, 2026 GLP-1 Bridge live at pharmacies; CMS Parts C & D appeals guidance update effective July 6, 2026 source
- Apr 21, 2026 BALANCE Part D component indefinitely delayed; Bridge extended through Dec 31, 2027 source
- Jan 1, 2026 Part D redetermination window changed 60 -> 65 days; 2026 appeal AIC thresholds $200 / $1,960 source
Bridge exclusions worth knowing: not available if your plan already covers a GLP-1 for you, or if you have T2D, moderate-to-severe OSA, or fatty liver disease — those route through standard Part D, where the indication-based PA is usually WINNABLE. Bridge copay does not count toward the $2,100 Part D out-of-pocket cap.
These are each payer's standard template. Employer plans customize them, so the same PBM can cover a drug for one employer and exclude it for another — a status here is a starting point, not your plan. A benefit exclusion is also a different fight from a PA denial. Always request your own plan's criteria in writing; you are entitled to them.