Anti-Obesity Medications (AOMs), or GLP-1s, have been all the rage in the news, on social media feeds, and throughout the health and wellness community. It has also been a major concern in the insurance and finance industries. I have often been asked in the past year by clients whether their Part D drug plans cover GLP-1 medications. And until now, my answer has always been that Medicare does not cover these medications unless you have a diagnosis of type 2 diabetes or other qualifying chronic conditions such as sleep apnea. This has been frustrating to many of my clients who are on it for weight loss and to prevent those chronic diseases related to obesity. Well, that has just changed!
Hold The Phone
Recently, the news hit big – Medicare is now covering GLP-1 medications for weight loss under the new Medicare GLP-1 Bridge Program! Up until now, changing the law to permit Medicare Part D plans to cover weight-loss medications would have required an act of Congress. However, CMS has the authority to test coverage changes through the Center for Medicare and Medicaid Innovation model or a ‘demonstration program.’ Agents have been reading up and attending educational seminars and webinars. We are here to help guide you on this latest development. Read on for more information and guidance on how this program came about, the cost, and who might qualify!
Demonstration Model
The program is short term, began on July 1st, 2026, and will extend through December 31st, 2027. It is run completely through Medicare – not the Part D insurance plan. Future planning is underway through the BALANCE model to ensure coverage through the Part D plans, but that will convert in 2028. More on that later. In the meantime, Medicare will manage approvals and partial payment of the medication. The current administration negotiated pricing for the program with three pharmaceutical manufacturers for three approved drugs. This will not run through the Part D plan, so it will not count toward the out-of-pocket copay max and will not affect the price of any of your other medications through your Part D plan.
What Does It Cost and Who Qualifies?
President Trump’s team negotiated a price of $245 per month for the approved GLP-1 drugs in the Bridge Program. The approved drugs are Wegovy (pill and shot form), Zepbound (shot form only), and Foundayo (pill form only). The price you pay, once approved, is $50 per month. However, if you already take those drugs, and they are approved through your Part D plan because of type 2 diabetes or other chronic medical conditions, you DO NOT qualify for the Bridge program. It is only for beneficiaries who do not have that diagnosis and thus cannot get it through their insurance. However, there are other rules to qualify. Here are the qualifying factors:
Must be 18 or older (yes, there are people under 18 on Medicare)
Have a Medicare Part D plan or Advantage Plan with drug coverage.
Need the GLP-1 for weight loss and maintenance of weight loss in these categories:
BMI of 35 or higher OR
BMI of 30 or higher AND have health conditions such as:
Heart Failure
Uncontrolled Hypertension
Chronic Kidney Disease
BMI of 27 or higher with one of these health risks:
Pre-Diabetes
Heart Attack
Peripheral Artery Disease
What is the Process?
Just like all other high cost or specialty medications, it starts with your physician. Talk with your physician to see if you may qualify. The physician must complete the order and request a Prior Authorization with Medicare. We are finding that they are working with pharmacies to do this. And remember, you must be enrolled in a Medicare Part D plan even though it is not going through your Part D plan.
Other Considerations
Since the program is not administered through your Part D plan, the $ 50-per-month fixed price remains the same. In other words, your drug deductible, copay tiers, and max out-of-pocket of pocket of $2100 annually do not apply.
If you have Extra Help or LIS, which subsidizes your prescription drug costs, and you qualify for the Bridge program, you still must pay the $50 per month for your GLP-1 drug. You do not get the Extra Help price for your other medications.
For more information, check out these reputable resources:
https://www.medicare.gov/publications/12234-medicare-glp-1-bridge-glp-1-drugs-for-50-a-month.pdf
https://www.goodrx.com/insurance/medicare/medicare-weight-loss-drugs
CDI is here to help you manage your healthcare costs and find the best options for your unique situation. We can meet in person or virtually. Reach out if you would like more information. Email carrie@cdi-cares.com or check out www.cdi-cares.com for a contact page and other helpful blogs.