Medicare GLP-1 Bridge: eligibility and prior authorization

The Medicare GLP-1 Bridge gives eligible Part D enrollees access to selected weight-management drugs outside the Part D payment system. It runs from July 1, 2026 through December 31, 2027, with a $50 monthly copay. The Part D deductible does not apply; the copay does not count toward Part D out-of-pocket spending, and the low-income subsidy does not reduce it. CMS program overview.

For clinics, the distinction between Part D and the Bridge determines where the request goes. A complete request sent to the wrong program still fails.

Check Part D before checking BMI

CMS directs patients with type 2 diabetes, moderate-to-severe obstructive sleep apnea, or noncirrhotic MASH with moderate-to-advanced fibrosis to Part D. A prescription intended to reduce major cardiovascular events also belongs with Part D, even when weight loss is another goal. The Bridge request form states these exclusions before its weight questions.

Record the actual diagnosis and prescribing purpose. A general fatty-liver entry does not establish MASH or its fibrosis stage. A sleep-apnea entry does not establish severity. The prescriber must resolve those clinical details before signing.

Recover the measurements from treatment initiation

The BMI threshold applies when GLP-1 treatment began. The patient must be at least 18, enrolled in an eligible Part D plan type, and receiving weight-management treatment with ongoing lifestyle modification. CMS eligibility criteria were checked September 13, 2026.

For the hypertension criterion, CMS specifies systolic pressure above 140 mm Hg or diastolic pressure above 90 mm Hg despite concurrent treatment with two antihypertensives. Keep the dated measurements and medication history with the request. If therapy began elsewhere, obtain that record; a lower current BMI does not replace the baseline.

The pharmacy claim starts the sequence

A Part D denial is unnecessary. The pharmacy must first send a claim to the Bridge using BIN 028918 and PCN MEDDGLP1BR. That establishes the patient for the authorization process. CMS pharmacy instructions.

If the pharmacy request has not arrived after 72 hours, CMS permits the prescriber to download and submit the fax form. Decisions are communicated within 72 hours of submission. The Bridge has no appeals process; corrected or additional information can support a resubmission. CMS prescriber process.

How Foresight helps

Foresight organizes weight-management evidence into dated measurements, comorbidities, and prior treatment history. Its pre-submission checks identify missing support and give the coordinator specific actions. That makes the baseline record easier to assemble and the prescriber's review easier to audit.

Keep the Bridge's criteria attached to the case. A commercial BMI check cannot establish Bridge eligibility. Assign pharmacy follow-up and any corrected resubmission to a named owner, with the last action and next step recorded.

For the surrounding workflow, see Foresight's prior authorization platform.