For twenty years Medicare could not pay for a drug prescribed to lose weight. In 2026 it still cannot, in the ordinary way; what changed is that a separate, temporary program now pays instead. Here is the structure, dated.
The exclusion
Section 1927(d)(2)(A) of the Social Security Act lists agents used for anorexia, weight loss or weight gain among the drugs a state Medicaid program may exclude. When Part D was written in 2003 it adopted that list as drugs outside the Part D benefit, so a Part D plan may not cover a GLP-1 prescribed for weight management, and a manufacturer savings card cannot be used by a Medicare enrollee. The exclusion is about the indication, not the molecule: the same Wegovy pen prescribed to reduce cardiovascular risk in a person with obesity (a March 2024 indication) is a covered Part D drug, and CMS said so in 2024.
What regular Part D covers
- Ozempic, the Ozempic pill and Mounjaro for type 2 diabetes.
- Wegovy for cardiovascular risk reduction in adults with established cardiovascular disease and obesity or overweight, and for noncirrhotic MASH.
- Zepbound for moderate-to-severe obstructive sleep apnea with obesity.
Each is subject to the plan's formulary, prior authorization and tier. Under the November 6, 2025 manufacturer agreement, the injectable products are priced at $245 per month to Medicare for all doses and indications (AMCP summary). Separately, semaglutide (Ozempic, Wegovy, Rybelsus) was selected for the second round of Medicare price negotiation; CMS's negotiated price of $274 per month takes effect January 2027. The 2026 Part D out-of-pocket cap is $2,100.
The Medicare GLP-1 Bridge
Announced by CMS on May 6, 2026, running July 1, 2026 to December 31, 2027:
- Copay: $50 per monthly prescription, flat across doses.
- Products: Wegovy in all formulations (pen and pill), Zepbound KwikPen only (single-dose vials and single-dose pens excluded), and Foundayo. Pen needles are not included.
- Who: Part D enrollees aged 18 or over prescribed the drug for weight management, meeting one of three pathways: BMI 35 or more; BMI 30 or more with heart failure, uncontrolled hypertension or chronic kidney disease stage 3a or worse; or BMI 27 or more with pre-diabetes, prior heart attack, prior stroke or symptomatic peripheral artery disease. All require ongoing lifestyle modification.
- Who not: anyone whose GLP-1 is for type 2 diabetes, moderate-to-severe sleep apnea or noncirrhotic MASH (covered under regular Part D instead), and anyone currently receiving a GLP-1 through their Part D plan.
- Mechanics: the Bridge operates outside the Part D benefit. Part D sponsors carry no risk, and the $50 does not count toward the Part D deductible or the out-of-pocket limit.
KFF estimated 3.8 million beneficiaries could be eligible. Lilly's November 2025 release had anticipated a start as early as April 1, 2026; the program began July 1.
BALANCE
The Bridge was designed as a stopgap ahead of the BALANCE model, a CMS Innovation Center test that would have let Part D plans and state Medicaid programs cover GLP-1s for obesity at the negotiated $245 price, originally scheduled for January 2027. In April 2026 CMS postponed BALANCE indefinitely and extended the Bridge through the end of 2027. Whether anything replaces the Bridge in 2028 is not decided as of the access date.
What a Medicare enrollee pays, by situation, September 2026
| Situation | What applies | Cost |
|---|---|---|
| Wegovy, Zepbound KwikPen or Foundayo for weight management, criteria met | GLP-1 Bridge | $50 per month, not counted toward Part D cap |
| Zepbound vial for weight management | not in Bridge; excluded from Part D | LillyDirect self-pay $299 to $449 |
| Wegovy for cardiovascular risk or MASH; Zepbound for sleep apnea | regular Part D | plan cost sharing; $2,100 cap in 2026 |
| Ozempic, Ozempic pill or Mounjaro for type 2 diabetes | regular Part D | plan cost sharing; negotiated semaglutide price from 2027 |
| Any manufacturer savings card | excluded | not available to government beneficiaries |
Lilly's and Novo Nordisk's Medicare pages both say eligibility is determined by CMS and that their information is not a guarantee of coverage; treat this page the same way. The Medicaid page covers the state programs, and the savings-card page explains why the cards stop at the Medicare line.
Questions people ask
I have Medicare and type 2 diabetes. Does the Bridge apply to me?
No. CMS excludes people whose GLP-1 is prescribed for type 2 diabetes, moderate-to-severe obstructive sleep apnea or noncirrhotic MASH from the Bridge, because those indications are already covered under regular Part D. Ozempic and Mounjaro for diabetes go through your Part D plan's formulary.
Does the $50 count toward my Part D out-of-pocket cap?
No. The Bridge operates outside the Part D benefit, so the $50 copays do not count toward the deductible or the annual out-of-pocket limit, per CMS, Novo Nordisk's Medicare page and the Medicare Rights Center.
Can I get Zepbound vials through the Bridge?
No. CMS states the single-dose vial and single-dose pen are not available through the Bridge; only the Zepbound KwikPen is, and pen needles are not included.
Sources
- Social Security Act section 1927(d)(2) (excludable drugs, including agents used for weight loss) Accessed September 4, 2026.
- CMS press release, May 6, 2026: $50 monthly access to GLP-1 medications for Medicare beneficiaries Accessed September 4, 2026.
- CMS: Medicare GLP-1 Bridge, information for providers (products, criteria, exclusions) Accessed September 4, 2026.
- Medicare.gov fact sheet: Medicare GLP-1 Bridge, GLP-1 drugs for $50 a month Accessed September 4, 2026.
- Medicare Rights Center, June 4, 2026: GLP-1 weight-loss drug demonstration begins July 2026 Accessed September 4, 2026.
- Novo Nordisk: Wegovy and Medicare Part D (Bridge, pen and pill, $50 not counted toward out-of-pocket) Accessed September 4, 2026.
- Lilly: Zepbound Medicare page (KwikPen only) Accessed September 4, 2026.
- NPR, May 6, 2026: some Medicare beneficiaries can now get obesity drugs for $50 a month (BALANCE model postponed indefinitely in April 2026) Accessed September 4, 2026.
- AMCP federal update: $245 per month Medicare and Medicaid price for injectable GLP-1s Accessed September 4, 2026.
- CMS: Medicare Drug Price Negotiation Program, selected drugs and negotiated prices (2027) Accessed September 4, 2026.
Canonical URL: https://formblendspricing.com/coverage/medicare. Written by the FormBlends editorial team. This page is educational and is not medical advice; see the medical disclaimer.