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Navigating the Medicare GLP-1 Bridge: What Pharmacy Teams Need to Know · Clinical Capsules - Actionable Medication Pearls in Minutes

• 0:05
  Narrator: Welcome to Clinical Capsules from TRC Healthcare, your trusted source for practical, evidence-based updates.
• 0:11
  Narrator: In this bonus episode, Associate Editor and Clinical Pharmacist Vickie Danaher gives you the scoop on everything pharmacy teams need to know about the Medicare GLP-1 Bridge, launching July 1st, 2026.
• 0:25
  Narrator: She covers which medications and patients are eligible, how to route claims correctly, and what to tell patients about their costs under this new CMS program.
• 0:33
  Narrator: This podcast offers continuing education credit for pharmacists and pharmacy technicians.
• 0:39
  Narrator: Please log into your pharmacist letter or pharmacy technician's letter account and look for the title of this podcast in the list of available CE courses.
• 0:47
  Narrator: None of the speakers have anything to disclose.
• 0:50
  Narrator: Catch new episodes of Clinical Capsules every second and fourth Tuesday.
• 0:56
  Narrator: Bring concise, actionable insights from TRC experts straight to your ears.
• 1:01
  Narrator: Let's take a closer look.
• 1:09
  Vickie Danaher: So today we're digging into something that's got a lot of pharmacy teams buzzing right now, and that's the Medicare GLP-1 Bridge.
• 1:16
  Vickie Danaher: So if you've been fielding questions from patients about their GLP-1 prescriptions and Medicare coverage, this episode is going to be really helpful.
• 1:25
  Vickie Danaher: The Medicare GLP-1 Bridge has a launch date of July 1st, 2026, which means that this is happening now, and there's some important workflow details that you and your team need to have locked down.
• 1:36
  Vickie Danaher: So we're going to walk through what this program actually is, which drugs are covered, who qualifies, and critically how to process these claims correctly.
• 1:46
  Vickie Danaher: There's some real nuances here that could trip up even experienced pharmacy staff.
• 1:51
  Vickie Danaher: So stick with me and let's get into it.
• 1:54
  Vickie Danaher: So first things first, what exactly is the GLP-1 Bridge?
• 2:03
  Vickie Danaher: The Medicare GLP-1 Bridge is a program from CMS, the Centers for Medicare and Medicaid Services, that allows eligible Medicare Part D patients to access certain GLP-1 agonist medications for weight management at a flat $50 copay per fill.
• 2:20
  Vickie Danaher: And we can think of this program as a temporary bridge to kind of open up and expand access to GLP-1s for obesity in Medicare patients while CMS evaluates what longer-term coverage will look like.
• 2:34
  Vickie Danaher: Now it's not a permanent fix.
• 2:37
  Vickie Danaher: This program is only slated to run from July 1st, 2026 through December 31st, 2027.
• 2:45
  Vickie Danaher: But it's a meaningful step forward for a lot of Medicare patients since we know that weight loss medications are excluded from Part D coverage under federal law.
• 2:56
  Vickie Danaher: Now, one of the most important things to take away from this episode is that the Medicare GLP-1 bridge operates completely outside of the Part D benefit.
• 3:07
  Vickie Danaher: So Part D plans are not processing these claims or covering any portion of the cost.
• 3:13
  Vickie Danaher: And the $50 copay that the patient pays is not going to count towards their Part D deductible or their annual out-of-pocket maximum.
• 3:22
  Vickie Danaher: So this is going to be a really common source of confusion.
• 3:25
  Vickie Danaher: Patients who are used to their spending counting towards their deductible or who have already met their deductible are going to need a clear explanation from your team.
• 3:35
  Vickie Danaher: So it's worth getting that talking point ready.
• 3:38
  Vickie Danaher: Next, let's talk about which medications are actually covered under the Medicare GLP-1 bridge, because not every GLP-1 is included.
• 3:50
  Vickie Danaher: And there's some specific formulation nuances that matter a lot at the dispensing level.
• 3:55
  Vickie Danaher: So as of launch, the covered medications include Orforglipron, which is brand name Foundayo, which is a newer oral GLP-1 agonist, semaglutide, available as either the oral tablets or the subcutaneous injection, branded as Wegovy, and then tirzepatide, but specifically the multi-dose pen, which is the Zepbound KwikPen.
• 4:23
  Vickie Danaher: Tirzepatide vials and single-dose pens are not covered under the bridge.
• 4:29
  Vickie Danaher: So that's an important distinction to flag with your team.
• 4:32
  Vickie Danaher: And then another exception is the GLP-1 liraglutide or Saxenda injection for weight loss.
• 4:40
  Vickie Danaher: It's not included either.
• 4:42
  Vickie Danaher: Now, one more thing on fills.
• 4:46
  Vickie Danaher: Only 28-day or 30-day supplies of the covered GLP-1s are allowed.
• 4:52
  Vickie Danaher: So there's no 90-day supplies or other extended fills through this program.
• 4:58
  Vickie Danaher: And I want to call out one more thing here that's critical to be aware of.
• 5:03
  Vickie Danaher: And that's the GLP-1 bridge is only for weight management.
• 5:08
  Vickie Danaher: If a patient is using a GLP-1 for type 2 diabetes, obstructive sleep apnea, or MASH, which is metabolic dysfunction associated steatohepatitis, those prescriptions will go through Part D as usual.
• 5:23
  Vickie Danaher: The bridge does not cover those indications, so you'll need to bill those prescriptions to Medicare Part D instead.
• 5:30
  Vickie Danaher: Again, the Medicare bridge only covers GLP-1 prescriptions used for weight management.
• 5:37
  Vickie Danaher: Now let's talk about patient eligibility because there's a clinical criteria component here that involves prior authorization.
• 5:47
  Vickie Danaher: To qualify for the bridge, patients must be using their GLP-1 for weight management, along with lifestyle modifications like diet, exercise, that kind of thing.
• 5:57
  Vickie Danaher: And they have to meet specific BMI or body mass index thresholds.
• 6:02
  Vickie Danaher: So patients will be eligible for the bridge if they have a BMI of 35 or higher, a BMI of 30 or higher with uncontrolled hypertension, chronic kidney disease stage 3A or above, or heart failure with preserved ejection fraction.
• 6:20
  Vickie Danaher: Or they may qualify if they have a BMI of 27 or higher with prediabetes as defined by the American Diabetes Association, symptomatic peripheral artery disease, or a prior heart attack or stroke.
• 6:36
  Vickie Danaher: Now, here's a nuance that's going to come up, and this one's easy to miss.
• 6:40
  Vickie Danaher: So the BMI that counts towards eligibility is the BMI at the time of GLP-1 initiation, not necessarily the patient's current BMI.
• 6:51
  Vickie Danaher: So let's say you have a patient who started their GLP-1 back in 2025 with a BMI of 36.
• 7:00
  Vickie Danaher: Well, now it's 2026 and the medication's working and their BMI is down to 32.
• 7:07
  Vickie Danaher: Well, that patient will still qualify for this program.
• 7:11
  Vickie Danaher: Their prescriber just needs to attest that the BMI criteria was met when therapy began, and that attestation is part of the prior authorization process.
• 7:21
  Vickie Danaher: So for this patient, the prescriber would attest that the patient's BMI was 36 when the GLP was started.
• 7:29
  Vickie Danaher: So they meet that BMI criteria of 35 or higher.
• 7:34
  Vickie Danaher: Okay, so now how do we flag which patients might be bridge eligible when a GLP-1 prescription comes in?
• 7:43
  Vickie Danaher: Well, there's a couple of things we can look for.
• 7:46
  Vickie Danaher: First would be looking for an obesity diagnosis code.
• 7:50
  Vickie Danaher: So those are in the E66 family, like E66.811 or similar.
• 7:57
  Vickie Danaher: Or there may be a notation in the prescription notes field that says something like, send to bridge for weight management.
• 8:04
  Vickie Danaher: So those will be clues to route the claim to the bridge.
• 8:08
  Vickie Danaher: And CMS is encouraging prescribers to include that information on prescriptions to help pharmacies route claims appropriately.
• 8:16
  Vickie Danaher: But note that this info isn't specifically required on the prescription in order for pharmacies to send it to the bridge.
• 8:23
  Vickie Danaher: Okay, so a prescription comes in for a covered GLP-1 medication, and you're thinking that the patient might be a candidate for the bridge.
• 8:33
  Vickie Danaher: Now, how do you actually process the claim?
• 8:36
  Vickie Danaher: Well, the good news is that pharmacies don't need to opt in to participate to this program.
• 8:41
  Vickie Danaher: There's no enrollment step on the pharmacy side, and patients don't need to sign up separately through Medicare or anything like that either.
• 8:49
  Vickie Danaher: But like I mentioned earlier, we in the pharmacy need to submit these claims to CMS's central processor for the bridge program, not the patient's Medicare Part D plan.
• 8:59
  Vickie Danaher: And to do that, there's some special claim routing information that you'll need to use.
• 9:04
  Vickie Danaher: So you'll want to write this down.
• 9:06
  Vickie Danaher: So for the Medicare GLP-1 bridge, the BIN number is 028918.
• 9:15
  Vickie Danaher: Again, that's BIN number 028918.
• 9:21
  Vickie Danaher: And then the PCN number is M E DD G L P 1BR.
• 9:33
  Vickie Danaher: So (med) M-E-D G- L- P-1 (the number one) B- R, like bridge.
• 9:42
  Vickie Danaher: And then for the patient ID, you'll need to use the patient's Medicare beneficiary identifier or MBI.
• 9:50
  Vickie Danaher: If you don't have the MBI or the patient doesn't have their Medicare card, you can do an E1 transaction to get that information like usual.
• 10:00
  Vickie Danaher: Now, one other thing to anticipate is that the patient's first fill through the bridge will require a prior authorization.
• 10:09
  Vickie Danaher: And here's another critical part.
• 10:12
  Vickie Danaher: The prescriber needs to submit that prior authorization to the bridge's program's central processor, not to the patient's Medicare Part D plan.
• 10:21
  Vickie Danaher: So if that PA goes to the wrong place, it's going to cause delays.
• 10:25
  Vickie Danaher: So make sure that you help direct prescribers to the right place up front.
• 10:30
  Vickie Danaher: And then a few more things on the financial side.
• 10:34
  Vickie Danaher: So patients will pay that flat $50 copay at the point of sale, and no discount cards or manufacturer savings programs can be applied to bridge claims.
• 10:45
  Vickie Danaher: So if a patient has a savings card they've been using, they won't be able to use it in conjunction with these claims.
• 10:51
  Vickie Danaher: And that's a conversation worth having proactively.
• 10:54
  Vickie Danaher: On the reimbursement side for your pharmacy, expect to be reimbursed at the medication's wholesale acquisition cost or WAC minus the $50 copay, plus a dispensing fee, either $3 for standard retail claims or $5 for beneficiaries in long-term care, plus sales tax where applicable.
• 11:17
  Vickie Danaher: All right, so that's the scoop on the new Medicare GLP-1 bridge program.
• 11:25
  Vickie Danaher: If you're walking away from this episode with three things, make them these.
• 11:29
  Vickie Danaher: One, the Medicare GLP-1 Bridge lets eligible Part D patients get covered GLP-1s for weight management for a $50 copay.
• 11:39
  Vickie Danaher: But this program operates outside of the Part D benefit, and that $50 does not count towards the patient's Part D deductible or out-of-pocket max.
• 11:49
  Vickie Danaher: Two, know your covered drugs, semaglutide oral or injectable, orforglipron, and tirzepatide multi-dose pen only.
• 11:59
  Vickie Danaher: No tirzepatide vials or single-use pens.
• 12:03
  Vickie Danaher: And again, these prescriptions must only be for weight management.
• 12:07
  Vickie Danaher: GLP-1 prescriptions for diabetes, sleep apnea, and MASH will still go through Medicare Part D.
• 12:14
  Vickie Danaher: Three, fill claims for the GLP-1 bridge to bin number 028918 PCN MED D GLP1BR and use the MBI for the patient's ID.
• 12:32
  Vickie Danaher: This will route claims to CMS's central processor, not the Part D plan.
• 12:37
  Vickie Danaher: And as with any new CMS program, keep an eye on the CMS Medicare GLP-1 Bridge website for any updates.
• 12:47
  Vickie Danaher: This program is new, guidance is evolving quickly, and details could change.
• 12:52
  Vickie Danaher: Also be sure to check out the GLP-1 and GIP, GLP-1 Receptor Agonist Interactive Comparison Chart on our Pharmacist Letter and Pharmacy Technicians Letter website.
• 13:04
  Vickie Danaher: It's a great resource if you need to compare products or think through any switches.
• 13:11
  Narrator: Thanks for listening.
• 13:12
  Narrator: We hope today's episode gave you practical insights you can use right away.
• 13:16
  Narrator: Now that you've listened, pharmacists and pharmacy technicians can receive CE credit.
• 13:20
  Narrator: Just log into your pharmacist letter or pharmacy technician's letter account and look for the title of this podcast in the list of available CE courses.
• 13:27
  Narrator: We've linked the resources we mentioned and more on today's topic right in the show notes.
• 13:33
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• 13:40
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• 13:52
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• 13:56
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• 14:01
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• 14:11
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• 14:13
  Narrator: Stay sharp, stay current, and join us next time on Clinical Capsules.