in 84 days LillyDirect self-pay — Foundayo™ (orforglipron) 2.5 mg moves to $199/month See the changelog
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Medicare (Part D + GLP-1 Bridge)

Federal program · updated September 16, 2026

Coverage right now

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

DrugStatusDetailConfidence
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. sourcehigh
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. sourcehigh
Wegovy® tablets (oral semaglutide)Covered
from Jul 1, 2026 to Dec 31, 2027
Bridge: covered, $50/month. sourcehigh
Foundayo™ (orforglipron)Covered
from Jul 1, 2026 to Dec 31, 2027
Bridge: all formulations, $50/month. foundayo.lilly.com· cms.govhigh
Ozempic® (semaglutide)Covered Part D for T2D under normal formulary rules (PA confirms diagnosis). NOT in the Bridge. medicarerights.org· cms.govhigh
Saxenda® (liraglutide)Excluded Not in the Bridge; Part D weight-loss exclusion applies. sourcehigh

What these rules come to in dollars — every dose, priced under this coverage:

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
Every category requires the beneficiary to be at least 18 years old — the Bridge is adults-only, with no pathway for a 12-to-17-year-old whose label allows the drug. 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, covering refills and dose changes — but not a switch to a different GLP-1, which needs a new PA.
Reauthorization
None during the Bridge window.
Step therapy
None.
Quantity limits
One-month supplies; $50 per fill.

Primary criteria document: cms.gov· medicare.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
Two different systems, and only one of them has an appeal. 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). Medicare GLP-1 Bridge: CMS states outright that there is no appeals process under the Bridge. A prescriber who believes a Bridge denial was made in error resubmits the prior authorization form with corrected, updated or additional information; there is no level above that, and none of the five Part D levels below applies to a Bridge denial.
Turnaround
Part D proper — coverage determination: 72h standard / 24h expedited. Redetermination: 7 days standard / 72h expedited. Bridge: the pharmacy transmits the PA request to the prescriber typically within 24-72 hours of the claim, and the approval or denial is returned within 72 hours of submission. If 72 hours pass with no request reaching the prescriber, they can download the fax form and submit it themselves.
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· 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. CMS now states both in its own words: the BALANCE page answers 'Will the Medicare GLP-1 Bridge continue into 2027?' with 'Yes. The Medicare GLP-1 Bridge has been extended through December 31, 2027', and both that page and the Bridge page carry a question about the impact of 'the BALANCE Model not launching in Medicare in 2027', saying the extension lets CMS collect GLP-1 utilisation data to share with Part D sponsors ahead of potential implementation of BALANCE in Part D 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 noncirrhotic MASH with moderate-to-advanced fibrosis (F2-F3) — those route through standard Part D, where the indication-based PA is usually WINNABLE. CMS's wording is that a beneficiary with one of those three diagnoses is ineligible for the Bridge even if they otherwise meet every clinical criterion. Cardiovascular disease is the deliberate exception and CMS says so outright: unlike the other three, the Bridge prior authorization does NOT ask the prescriber to attest that the beneficiary has no established cardiovascular disease, so a Wegovy user with a MACE-risk-reduction indication is not shut out of the Bridge the way a T2D or OSA patient is — the attestation only has to say the drug is prescribed to reduce excess weight and maintain the reduction. Bridge copay does not count toward the $2,100 Part D out-of-pocket cap; CMS puts it as no part of the $50 counting toward TrOOP, the Part D deductible not applying, and no low-income subsidy for LIS beneficiaries.
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.