Some Medicare patients will be able to get GLP-1 medication for weight loss starting July 1 through a new pilot program with a $50 monthly copay.
The Medicare GLP-1 Bridge program expands access to weight-loss drugs made by Eli Lilly and Novo Nordisk, including Zepbound, Foundayo, and Wegovy.
“Medicare is not changing the law right now,” said Juliette Cubanski, vice president and director of Medicare policy at the health care research nonprofit KFF. “What it’s doing is taking advantage of a specific section of the law that gives the federal government the ability to stand up a temporary program.”
Patients could lose access after the 18-month trial ends Dec. 31, 2027, unless the Centers for Medicare & Medicaid Services extends it or Congress changes the law.
“In the short term, we have this temporary program, and then no clear path forward yet as to what will happen at the end of 2027,” she said.
Medicare beneficiaries with Part D coverage who are enrolled in an eligible plan can receive coverage through the Bridge program. To qualify, a provider must submit a prior authorization request showing the patient is being prescribed a GLP-1 for weight loss.
Providers must also show patients meet clinical criteria when they start treatment. Patients must have either a body mass index of at least 35; a body mass index of at least 30 plus a history of heart failure, uncontrolled hypertension, or chronic kidney disease; or a body mass index of at least 27 plus prediabetes, a previous heart attack or stroke, or symptomatic peripheral artery disease.
Patients are not eligible if they already have a GLP-1 prescription under Medicare Part D for certain conditions, such as Type 2 diabetes and sleep apnea, according to Cubanski.
“Certainly, for patients who may think that they’re eligible for these drugs or are interested in exploring whether they’re eligible, a good first step is to talk to their clinician who can help them,” Cubanski said.
The $50 copay will not count toward a patient’s deductible or annual out-of-pocket cap because the program is outside Medicare Part D coverage. Patients also cannot use coupons or discounts to reduce the price further.
“The good news is they don’t have to meet their deductible in order to qualify for the $50 copay,” Cubanski said. “But on the other hand, the $50 copay doesn’t count towards their $2,100 out-of-pocket cap.”