Does Medicare Cover Wegovy or Zepbound? (2026–2027)

What This Means

The Medicare GLP-1 Bridge — a temporary CMS demonstration that covers Wegovy (semaglutide injection and tablets), Zepbound (tirzepatide, KwikPen only), and Foundayo (orforglipron tablets) for weight loss — runs from July 1, 2026 through December 31, 2027 and charges a flat $50 copay per one-month supply to Part D enrollees age 18 or older who meet a BMI test (CMS; CMS provider FAQ). If you think you qualify, ask your prescriber to send a prescription for one of these drugs to your pharmacy — the pharmacy’s first claim triggers the prior authorization (Medicare.gov).

This is the first time Medicare has paid for weight loss drugs. Federal Part D rules exclude drugs used for weight loss from coverage — the exclusion is written into the definition of a “Part D drug” at 42 CFR 423.100, which carries forward the Medicaid exclusion list in section 1927(d)(2) of the Social Security Act — and that exclusion has not been repealed. The Bridge works around it: CMS runs it under separate demonstration authority, and the drugs must be prescribed to reduce excess body weight and maintain weight reduction in combination with lifestyle modification (CMS).

The Bridge operates outside of your normal Part D benefit. That means it is not run by your Part D plan. Instead, prior authorization and claims go through a central CMS processor — CMS has named Humana, which already administers the LI NET program, for that role. You still need to be enrolled in an eligible Part D plan to qualify, but the Bridge itself is a separate CMS program, and the $50 copay does not change with the drug’s retail price or with where you are in your Part D benefit phases.

This program is temporary, but it runs longer than originally announced. CMS first set it to expire at the end of 2026, with coverage continuing only through Part D plans that joined a new model called BALANCE. BALANCE is not launching in Medicare in 2027, and CMS extended the Bridge through the end of 2027 instead (CMS BALANCE Model FAQ). Because the Bridge sits outside the Part D benefit and does not depend on your plan’s formulary, you do not need to change Part D plans this fall to keep this coverage — we cover what that means in detail below.

Who Qualifies

To be eligible for the Medicare GLP-1 Bridge, you must be enrolled in an eligible Part D plan — a standalone drug plan (PDP), a Medicare Advantage coordinated-care plan with drug coverage (HMO, HMO-POS, or PPO), a Special Needs Plan, an employer/union group waiver plan, or the LI NET program — and you must be age 18 or older. You must also have met one of the following BMI-based criteria at the time you started GLP-1 therapy (Medicare.gov; CMS provider FAQ).

Two groups are not eligible even if they meet the BMI test, according to CMS (provider FAQ):

• People whose GLP-1 is already coverable under Part D. Type 2 diabetes, moderate-to-severe obstructive sleep apnea, and noncirrhotic MASH (fatty liver disease with moderate-to-advanced scarring) are Part D-covered uses. If you have one of these three diagnoses, your Part D plan — not the Bridge — is the route, and the Bridge prior-authorization form tells your prescriber to send the request to your plan instead. Sleep apnea and MASH are not Bridge qualifying conditions; they are reasons the Bridge does not apply. Heart disease itself does not disqualify you — a prior heart attack, stroke, or symptomatic peripheral artery disease is a qualifying condition at BMI 27 or higher. But if the drug is being prescribed to reduce your risk of a heart attack or stroke rather than for weight loss, that request also goes to your Part D plan, not the Bridge.
• People already getting a GLP-1 through their Part D plan. Medicare.gov says that if your drug plan has been paying for your GLP-1, you are not eligible for the Bridge but can keep getting the drug through your plan (Medicare.gov).

If your BMI has dropped since you started a GLP-1, the criteria are applied to your BMI when therapy began — CMS’s example is a patient who started at a BMI of 37 and is at 34 when the Bridge request is filed, who still qualifies under the 35-or-higher tier. Your provider documents your BMI and any qualifying condition on the prior authorization. If you are not sure whether you meet the criteria, talk to your doctor, or use the eligibility checker on Medicare.gov.

What It Costs

You will pay a $50 copay to the pharmacy for each one-month supply (28 or 30 days, depending on the drug). That is the same whether you get Wegovy, Zepbound, or Foundayo, and it does not change based on where you are in your Part D benefit year (Medicare.gov; CMS).

There are important limitations to understand about this $50 copay:

• It does not count toward your Part D deductible. You still need to meet your regular Part D deductible separately for your other medications.
• It does not count toward the $2,100 annual out-of-pocket cap (the 2026 Part D cap, per the CMS Part D redesign instructions). The $50 you pay for each Bridge fill will not bring you closer to the Part D out-of-pocket maximum. It is entirely separate spending, and it will not appear on your Part D Explanation of Benefits.
• Extra Help (Low-Income Subsidy) does not apply. Even if you qualify for Extra Help, which normally reduces or eliminates copays on Part D drugs, the $50 Bridge copay is not reduced. You will pay the full $50.
• Coupons and discount programs cannot be used. CMS bars pharmacies from applying manufacturer coupons or other discount programs to Bridge claims, regardless of who funds them (CMS pharmacy FAQ).
• It cannot be spread across months with the Medicare Prescription Payment Plan (Medicare.gov).

The $50 copay is a fixed cost set by CMS for this demonstration program. It is not subject to the normal Part D cost-sharing rules.

How to Get It

1. Talk to your doctor. Tell your doctor you are interested in Wegovy, Zepbound, or Foundayo for weight loss under the Medicare GLP-1 Bridge. Your doctor will evaluate whether you meet the BMI and health condition requirements and whether one of these medications is appropriate for you. The prescription must be for weight loss with lifestyle modification — your provider has to certify that you are using the drug as part of a program focused on diet and exercise (Medicare.gov).
2. Your doctor sends the prescription to your pharmacy, and the pharmacy’s claim triggers the prior authorization. This is different from a normal Part D prior authorization. When the pharmacy runs the claim through the Bridge, it sends a prior authorization request to your prescriber (CMS says typically within 24–72 hours), and your prescriber submits the completed request to CMS’s central processor — not to your Part D plan. CMS says the approval or denial is mailed to you and sent to your prescriber within 72 hours of submission (CMS provider FAQ). Your doctor’s office handles this paperwork; if your prescriber has not received the request from the pharmacy after 72 hours, they can submit the CMS form directly.
3. Fill your prescription. Once the prior authorization is approved, you will get a letter in the mail confirming coverage, and you pay the $50 copay at the counter. The pharmacy processes the claim through the Bridge program, not through your regular Part D plan. An approval stays valid — including for refills and dose changes — through December 31, 2027, unless you switch to a different covered GLP-1 (Medicare.gov; CMS pharmacy FAQ).

If the prior authorization is denied, there is no Bridge appeal. CMS states plainly that there is no appeals process under the Medicare GLP-1 Bridge (CMS provider FAQ). Your prescriber can submit a new request if the first one was missing information, but the Part D coverage-determination and appeal rights described in our prescription drug denied guide apply to your Part D plan’s decisions, not to the Bridge — CMS says the Bridge does not change those Part D rights either way (CMS Part D plan FAQ).

One important exception: If the drug you need is already coverable under your Part D plan for a different medical reason, the Bridge does not apply. For example, semaglutide is also sold as Ozempic for type 2 diabetes, and tirzepatide is also sold as Mounjaro for type 2 diabetes. If your doctor prescribes a GLP-1 for diabetes, sleep apnea, MASH, or cardiovascular risk reduction (or another Part D-covered condition), you would get it through your regular Part D benefit with your plan’s normal cost-sharing (CMS provider FAQ). The Bridge is specifically for Wegovy, Zepbound, and Foundayo prescribed for weight loss.

What Happens When the Bridge Ends

The GLP-1 Bridge runs through December 31, 2027 — a year longer than CMS first announced (CMS).

The original plan was for the Bridge to expire on December 31, 2026, with coverage continuing in 2027 only through Part D plans that volunteered for a new CMS model called BALANCE. That is no longer what is happening. BALANCE is not launching in Medicare in 2027, and CMS extended the Bridge through the end of 2027 in its place — in CMS’s words, to keep access open while it collects utilization data to share with Part D plan sponsors “ahead of potential implementation of BALANCE in Part D” (CMS BALANCE Model FAQ). Potential: CMS has not announced a start date for BALANCE in Medicare. KFF reports that CMS made the change on April 21, 2026, the day after the Part D sponsor application deadline, and that the applying plans appear to have fallen short of CMS’s 80%-of-enrollment participation threshold (KFF).

What this means for you right now:

• You do not need to switch Part D plans this fall to keep GLP-1 coverage. The open enrollment period running October 15 through December 7, 2026 has no bearing on your Bridge eligibility. The Bridge operates outside the Part D benefit, so no plan’s formulary decision can take it away, and no plan choice can secure it — and an approved Bridge prior authorization stays valid through December 31, 2027. If you are comparing plans for other reasons — your other medications, premiums, pharmacy networks — weigh those on their own merits.
• You do need to stay enrolled in an eligible Part D plan. Part D enrollment (a standalone PDP or a Medicare Advantage coordinated-care plan with drug coverage) is an eligibility requirement for the Bridge. If you drop Part D altogether, you lose access to it.
• Revisit this at the end of 2027, not the end of 2026. CMS has not said what, if anything, replaces the Bridge on January 1, 2028. Watch for CMS guidance during 2027, and talk to your doctor about continuity of your medication then.

If you were told earlier in 2026 that you would need to find a BALANCE plan for 2027, that guidance reflected the original schedule and is now out of date.

Important Limitations

• Only Wegovy, Zepbound (KwikPen), and Foundayo are covered. CMS lists all formulations of Wegovy and Foundayo but only the KwikPen formulation of Zepbound — the single-dose vials and single-dose pens are not available through the Bridge (CMS provider FAQ). The Bridge does not cover other GLP-1 medications like Ozempic, Mounjaro, or Saxenda. Ozempic and Mounjaro are the diabetes-approved versions of the same active ingredients — they may be covered under your regular Part D benefit when prescribed for diabetes.
• The drug must be prescribed for weight loss. If your doctor prescribes the medication for a condition already covered by Part D (type 2 diabetes, sleep apnea, MASH, or to reduce cardiovascular risk), use your regular Part D benefit instead — the Bridge does not apply. Having type 2 diabetes, moderate-to-severe sleep apnea, or MASH makes you ineligible for the Bridge; a heart-disease diagnosis does not, as long as the drug is prescribed for weight loss.
• The $50 copay does not count toward your Part D deductible or the $2,100 out-of-pocket cap. This spending is entirely separate from your normal Part D benefit.
• Extra Help (Low-Income Subsidy) does not reduce the $50 copay, and neither can coupons or discount cards. You pay the full $50 regardless of your income level.
• There is no appeal if a Bridge prior authorization is denied. CMS says there is no appeals process under the Bridge; your Part D appeal rights apply only to your plan’s own decisions.
• The program is temporary. Coverage under the Bridge runs July 1, 2026 through December 31, 2027. CMS has not announced what replaces it afterward, and BALANCE — the model once slated to take over in 2027 — is not launching in Medicare that year.
• Prior authorization goes to CMS, not your Part D plan. Your prescriber submits the prior authorization to CMS’s central processor (Humana), not to your Part D plan’s pharmacy benefit manager. CMS has described this single-central-processor arrangement for 2026; it has not yet said whether the same setup carries into 2027, though approvals already issued are valid through the end of 2027.
• Weight loss drugs are still excluded from Part D by rule. The Bridge is a CMS demonstration program. The Part D exclusion at 42 CFR 423.100 remains in place. The Bridge works around it, not through it.

Sources

• CMS: Medicare GLP-1 Bridge — official program page; primary source for the July 1, 2026 – December 31, 2027 operating window, the $50 copay, the deductible/out-of-pocket/Extra Help exclusions, and the extension made after BALANCE did not launch for 2027
• CMS: Medicare GLP-1 Bridge — Information for Providers — covered drugs and formulations, the BMI and qualifying-condition criteria, the Part D-covered diagnoses that make a beneficiary ineligible, the prior authorization process and 72-hour decision, and the statement that there is no appeals process under the Bridge
• CMS: Medicare GLP-1 Bridge — Information for Pharmacies — Humana as central processor, eligible plan types, the coupon prohibition, and prior authorization approvals valid through December 31, 2027
• CMS: Medicare GLP-1 Bridge — Information for Part D Plans — the Bridge does not modify Part D appeal or exception rights
• Medicare.gov: Medicare GLP-1 Bridge — beneficiary-facing eligibility checker, $50 per one-month supply, coverage letter, prior authorization validity, and the Prescription Payment Plan exclusion
• 42 CFR 423.100 — definition of “Part D drug” — Part D exclusion of drugs on the section 1927(d)(2) Medicaid list, which includes weight loss agents
• CMS: Final CY 2026 Part D Redesign Program Instructions — the $2,100 annual out-of-pocket threshold for 2026
• Medicare.gov: Joining a plan — the October 15 – December 7 open enrollment period
• KFF: What to Know About the BALANCE Model for GLP-1s in Medicare and Medicaid — background on the BALANCE Model and the April 21, 2026 decision not to launch it in Medicare for 2027
• CMS: BALANCE Model — the model CMS had planned to run in 2027; its FAQ confirms the Bridge extension through December 31, 2027

Frequently Asked Questions