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This article is an update to the special announcement newsletter we sent out in June, which indicated we would be forwarding instructions for submitting prescriptions and for beneficiaries obtaining covered medications beginning July 1, 2026.
Medicare is launching the GLP‑1 BALANCE Bridge Demonstration, a temporary program that allows eligible Medicare beneficiaries who are enrolled in a Part D drug plan (either Medicare Advantage Prescription Drug Plan or stand-alone Part D coverage) to receive one of these weight loss medications--Foundayo (orforgliprom) (all formulations), Wegovy (semaglutide) (all formulations), and Zepbound (tirzepatide) (Kwikpen only)-- for a flat $50 per month, regardless of dose. The program uses a single national processor to handle all prior authorizations and pharmacy claims and follows a different procedure than is followed for drugs covered under Part D of Medicare.
This document was published very recently by Medicare (CMS) and will be updated regularly. Because this program is structured differently from anything that has previously existed in Medicare, we expect significant confusion among prescribers, pharmacies, and beneficiaries.
Doctors and pharmacies may not have received this information, so we suggest making a copy of the document and presenting it to both your pharmacy and doctor. The program is beginning to receive significant media attention and there is much incorrect information being circulated.
STEP-BY-STEP INSTRUCTIONS FOR OBTAINING MEDICATIONS UNDER THIS PROGRAM:
For the patient/beneficiary:
1. Talk to your doctor about whether a GLP-1 drug is right for you and whether you meet the BMI/clinical criteria (BMI ≥35 alone; BMI ≥30 with certain conditions like heart failure, uncontrolled hypertension, or CKD stage 3a+; or BMI ≥27 with prediabetes, prior heart attack/stroke, or PAD).
2. Doctor sends the prescription to your pharmacy for one of the covered drugs (Wegovy, Zepbound KwikPen, or Foundayo).
3. Pharmacy may ask for your Medicare ID (or last 4 digits of your SSN if you don't have your card, so they can look up your number).
What happens at the pharmacy (the claims mechanics)
4. The pharmacy electronically submits the claim to the Bridge's central processor (not your regular Part D plan), using the NCPDP Telecommunication Standard, with a Bridge-specific Bank Identification Number and Processor Control Number (028918 MEDDGLP1BR).
5. Even for an eligible patient, the Bridge will initially deny the claim — but this denial automatically triggers a prior authorization (PA) requirement, and the pharmacy sends that PA request form to your prescriber, typically within 24–72 hours.
Prior authorization (prescriber's role)
6. Your prescriber confirms you're in an eligible Part D plan type, haven't already gotten a GLP-1 through Part D, and don't have type 2 diabetes, moderate-to-severe sleep apnea, or MASH (Metabolic Dysfunction-Associated SteatoHepatitis) — then confirms you meet the BMI/diagnosis criteria. Please see this guide for doctors and prescribers that was published in Medicare Tools on June 25.
7. The prescriber includes an obesity diagnosis code from the E66 family and a note like "SEND TO BRIDGE FOR WEIGHT MANAGEMENT" on the prescription so it routes correctly — otherwise the claim could default to your Part D plan and trigger a different process.
8. The prescriber completes and submits the PA form, attesting under penalty of perjury to your BMI/clinical criteria at the time therapy was initiated (even if your BMI has since changed). [Note: the PA form for the Bridge program is available at https://www.cms.gov/glp-1-bridge.pdf and includes clinical criteria, required documentation, and prescriber attestations.]
9. CMS's central processor reviews and approves/denies the PA.
After approval
10. Once approved, you pick up your first fill for a $50 copay (only 28- or 30-day fills are covered).
11. Subsequent refills don't need a new PA — unless you switch to a different covered GLP-1 drug, which requires a fresh prior authorization.
A few important caveats:
- Paper claims and direct member reimbursements are not accepted — everything must go through the electronic central processor.
- Coupons and manufacturer discount programs can't be applied to Bridge claims.
- Pharmacies don't need to opt in to participate.
- Patients themselves can't submit the PA paperwork — it must come from the prescriber.
For program questions, contact CMS at glp1demo@cms.hhs.gov or visit the CMS Medicare GLP-1 Bridge webpage. Please call us at 786-970-0740 (Cell) or 561-734-3884 / 877-734-3884 (TTY: 711) with any questions about this program or for help determining whether you may qualify.
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