Some Medicare beneficiaries can now get prescription weight-loss medications for $50 a month — even if they don’t have diabetes.
The Medicare GLP-1 Bridge program, which began July 1, provides eligible beneficiaries access to certain medications for weight management. The temporary program runs through Dec. 31, 2027, according to the Centers for Medicare & Medicaid Services.
For people who have struggled with their weight and the cost of treatment, the program creates an opportunity to discuss medication with their health care provider. But having Medicare or wanting to lose weight does not automatically qualify someone.
Who Qualifies?
Participants must have eligible Medicare Part D prescription drug coverage, either through a standalone drug plan or a qualifying Medicare Advantage plan that includes drug coverage.
They must also be at least 18 and meet one of these requirements when starting treatment:
- BMI of 35 or higher, without an additional qualifying condition.
- BMI of 30 or higher, along with certain heart failure, uncontrolled high blood pressure or chronic kidney disease at stage 3a or higher.
- BMI of 27 or higher, along with prediabetes, a previous heart attack or stroke, or symptomatic blocked arteries in the arms or legs.
BMI, or body mass index, is calculated using height and weight. A health care provider can determine whether a patient meets the requirements.
The blood-pressure requirement is specific: CMS defines it as blood pressure above 140 systolic or 90 diastolic despite treatment with two blood-pressure medications. The qualifying heart failure condition is heart failure with preserved ejection fraction.
Diabetes Is Not Required
The Bridge is intended for people seeking medication for weight management who would not otherwise qualify for GLP-1 coverage through Medicare Part D.
People with type 2 diabetes, moderate-to-severe obstructive sleep apnea or certain advanced fatty liver disease may qualify for GLP-1 medication through their regular drug plan instead. They are excluded from the Bridge, and their costs depend on their plan’s coverage rules.
How To Get Started
The first step is an appointment with a doctor or other prescribing health care provider. Patients can ask whether they qualify for the Medicare GLP-1 Bridge and whether treatment is appropriate for them.
Covered products include Foundayo tablets, Wegovy injections or tablets, and Zepbound’s KwikPen. Zepbound single-dose pens and vials are not included.
The provider sends a prescription to the pharmacy and completes prior authorization when requested. The provider must also certify that the medication accompanies a lifestyle program addressing diet and exercise.
Medicare says patients will receive a coverage letter by mail.
Part D insurers do not have to opt into the Bridge for eligible members to participate, according to CMS.
Why Consider Treatment?
Weight-loss medication can help some people manage hunger and maintain weight loss when combined with changes in eating and physical activity.
The potential benefits extend beyond the scale. According to the National Institute of Diabetes and Digestive and Kidney Diseases, losing 5% to 10% of starting weight may improve blood pressure, blood sugar and triglyceride levels. Weight loss may also ease joint pain and sleep apnea.
For someone weighing 200 pounds, that means losing 10 to 20 pounds. Results vary, and medication does not replace healthy eating and physical activity.
Understand the Costs and Risks
The $50 monthly copayment totals $600 for 12 monthly fills. However, those payments do not count toward a beneficiary’s Part D deductible or annual out-of-pocket limit. Medicare’s low-income drug subsidies do not reduce the Bridge copayment.
Patients should also discuss side effects and medical history with their provider. Common side effects can include nausea, vomiting, diarrhea and constipation. Depending on the medication, serious risks include pancreatitis, gallbladder problems and dehydration-related kidney injury. Certain thyroid cancer histories can rule out some medications.
Because the program is temporary, patients should ask how they would continue treatment after December 2027.
To check eligibility or get help, visit Medicare.gov/glp1bridge or call 1-800-MEDICARE (1-800-633-4227).