The federal government has initiated a trial program offering Medicare beneficiaries access to certain GLP-1 weight loss drugs for $50 per month. The initiative, known as Medicare GLP-1 Bridge, commenced on Wednesday and will continue through the end of 2027.
This program represents a significant, albeit temporary, opportunity for many older Americans to have weight loss medications covered by insurance. Previously, Medicare coverage for these drugs was primarily limited to beneficiaries with conditions like diabetes. The new trial, however, focuses on weight loss as a primary indication, though eligibility is contingent on specific health and weight requirements.
Dr. Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services (CMS), stated that the program is intended to gather data that could inform future, long-term coverage decisions. He also emphasized its role in providing immediate financial relief to beneficiaries struggling with the high cost of these medications.
To qualify for the Medicare GLP-1 Bridge program, beneficiaries must have Medicare drug coverage and meet certain body mass index (BMI) criteria. Specifically, individuals with a BMI of 35 or higher are eligible. Those with a BMI of 27 or higher can also qualify if they have an accompanying health condition, such as a history of heart attack, stroke, or prediabetes. The BMI threshold is assessed at the initiation of GLP-1 therapy, meaning individuals who previously met the criteria but have since fallen below it may still be eligible.
However, beneficiaries diagnosed with sleep apnea, diabetes, or fatty liver disease are excluded from this specific program. These individuals may still have their GLP-1 medications covered by their Medicare Part D insurance if prescribed for those particular conditions.
Eligible beneficiaries interested in the program are advised to consult their healthcare provider. The provider must submit a prescription for a covered GLP-1 drug to a pharmacy and complete a prior authorization form. The medications included in the program are Eli Lilly's Foundayo tablets and Zepbound KwikPens, and Novo Nordisk's Wegovy injections and tablets, all of which have received FDA approval for weight loss.
Under the Bridge program, the cost for beneficiaries is a flat $50 per month, irrespective of dosage. These payments do not count toward insurance deductibles or out-of-pocket maximums, as Medicare itself is subsidizing the prescription costs.
The program's temporary nature stems from current congressional authorization, which does not permit permanent Medicare coverage for weight loss drugs. Future coverage could be established through legislative action by Congress or potentially through other CMS pilot programs, such as the previously delayed BALANCE initiative.
Oz indicated that CMS will closely monitor participation and outcomes from the Bridge program to guide decisions on its extension or the adoption of alternative solutions. He noted that permanent, government-wide coverage is a matter for congressional debate.
GLP-1 drugs have gained widespread popularity for their effectiveness in promoting significant weight loss, but their high retail prices have presented a substantial barrier to access for many. The Medicare GLP-1 Bridge program aims to alleviate some of that financial burden for a specific segment of the Medicare population.