7 things to know about Medicare’s new GLP-1-based medication coverage

For decades, it’s been against the law for Medicare to pay for weight-loss medication.

But that changed on July 1, with the launch of a new program called Bridge. It gives some people over 65, or who have Medicare for other reasons, access to some weight management medications if they meet certain weight and health criteria. 

Doctors who specialize in treating obesity, and study its impact on individuals and society, welcome this shift. The policy began in the previous presidential administration, as recognition grew that obesity is disease with complex causes and effective treatments. 

But the new program doesn’t cover all those treatments, nor the services that can help people achieve and sustain weight loss over the long term. And it’s only open to people who meet certain health criteria.

Lauren Oshman, M.D., M.P.H., a physician who is board-certified in family medicine and obesity medicine, has been preparing for the program’s launch for months. 

She welcomes it, not only for her own patients at University of Michigan Health’s Chelsea Family Medicine clinic, but also for the primary care clinics across Michigan that she’s advising as a leader of a statewide effort to improve Type 2 diabetes prevention and care. 

Oshman has been thinking about Medicare coverage of GLP-1 drugs for years, because of her research focus in Type 2 diabetes and obesity. In 2023, she worked with the U-M National Poll on Healthy Aging to survey Americans between the ages of 50 and 80 on the subject. 

Nearly 76% of older adults responding to that survey felt that Medicare should cover weight-loss medication. Last year, the team published a paper with further analysis of the data. 

The poll also found that 60% of Americans aged 50 to 80 in 2023 who had a body mass index (BMI) of 30 or above were interested in taking a weight management medication. A BMI of 30 is typically used as a cutoff for obesity, while 25 is used as the cutoff for overweight.

“Based on our data, and on the calls to my clinic in the last few weeks, I think there is going to be robust demand under the Bridge program,” said Oshman. “I’m thrilled that GLP-1- based medications like semaglutide (Wegovy) and tirzepatide (Zepbound) are going to be covered under Medicare, but several important medications are not. And it takes more than just a prescription to achieve sustained weight loss and the health benefits that go along with it. It takes wraparound services and support, none of which is addressed in the Bridge program.” 

Here are key things to know: 

1: Not everyone with Medicare qualifies for GLP-1 coverage.

To be eligible for the Bridge program, you have to have Part D prescription drug coverage through Medicare, either one that you buy directly or one that’s included in a Medicare Advantage plan, or a Medicare Special Needs Plan.

If you get some or all of your health coverage through Medicare, but you get your prescription drug benefit through a retirement plan from a previous employer or union, you may not be eligible for GLP-1 drug through Bridge. You must check to see if your plan is considered an “employer/union group waiver plan (EGWP)”; contact your benefits management office to be sure.

If you do have Part D coverage, you can’t join the Bridge program if you’re already getting, or are eligible to get, a GLP-1-based medication covered by Medicare for another reason. 

For instance, if you have Type 2 diabetes, which was the first condition for which GLP-1 drugs were approved by the U.S. Food and Drug Administration, you can’t get a GLP-1 through Bridge. 

In addition, some GLP-1 drugs have gotten additional FDA approvals for reduction of cardiovascular disease risk and treatment of sleep apnea and fatty liver disease (also called MASHLD and AFLD) in people with overweight or obesity. If you have these conditions or Type 2 diabetes, you can get a GLP-1 medication covered through Medicare Part D and you are not eligible for a GLP-1 through Bridge.

Even if you have qualifying Medicare drug coverage and aren’t eligible for a GLP-1 through these conditions, you have to meet Bridge’s BMI and health criteria. (Calculate your BMI based on height and weight here.)  

Anyone with a BMI of 35 and over qualifies for a GLP-1 under Bridge.

If your BMI is 27 or over, you may qualify if you have prediabetes (with a blood sugar A1C level of 5.7 to 6.4), a history of heart attack or stroke, or blocked leg arteries that cause symptoms. 

If you don’t have one of those conditions but your BMI is between 30 and 34.9, you may qualify if you have chronic kidney disease, uncontrolled high blood pressure (hypertension) or heart failure with preserved ejection fraction. 

Oshman said, “If you are current taking a GLP-1-based medication and you’re paying for it out of pocket, it’s important for your clinician to submit your BMI and weight as they were before you started the medication.” Make sure your clinician has all of your weight data. 

2. You can’t apply to the Medicare GLP-1 program directly.

Getting into the Bridge program requires that you have a doctor, nurse practitioner or physician assistant prescribe an eligible GLP-1-based medication and attest to the Medicare program that you qualify under Bridge’s prior authorization criteria. They must also certify that you’re going to use the drug along with modifying your lifestyle through diet and exercise.

They then send the prescription to a pharmacy, and the pharmacist must work through Medicare’s system to get the approval completed. If it is, you will get a letter in the mail saying you are approved. Only then can you start picking up the prescription and using it. 

If your prescriber or pharmacist is not familiar with the Bridge program, there’s a website for them here.

3. It costs $50 a month and that doesn’t apply to your prescription spending cap.

Many people with Medicare drug coverage have a deductible, and everyone has a cap on the total amount they have to pay for drugs each year. But the Bridge program is outside of both of these. 

People approved for GLP-1 coverage under the Bridge program will pay $50 a month for their prescription. 

Someone who gets a GLP-1 drug for diabetes or another non-weight loss reason under Medicare might be paying more per month on average, depending on whether they have a deductible or not. Someone buying a GLP-1 drug directly for weight loss might pay about the same, or more, depending on which service they choose and whether it offers more support beyond just a prescription.

People who have a low income and are eligible for Medicare programs that reduce drug costs (such as the Extra Help program) will not get that discount for the Bridge program.

The $50 a person will pay per month under Bridge will not be counted toward the $2,100 maximum that a person with Medicare drug coverage would have to pay in 2026; this cap rises to $2,400 in 2027. 

So even if a person is on a Bridge GLP-1 for all of 2027, the $600 they would pay would not get added to their other prescription drug spending; they would have to spend $2,400 on other drugs to hit the cap and get the rest of their drugs for the year at no cost to them.

4. Not all GLP-1 drugs are covered by Medicare Bridge.

There are multiple GLP-1 medications, also called incretin mimetics, on the market, Oshman notes, in multiple doses. Many have years of evidence behind them. But the program focuses on three:

• Orforglipron (Foundayo), a once-daily tablet that can be taken by mouth without food or water and in clinical trials led to an 11% weight reduction in 16 months; 

• Semaglutide (Wegovy pill), a once-daily tablet that must be taken with a small amount of water first thing in the morning, a half hour before any food and semaglutide (Wegovy injection), or a weekly injection through a pen that must be kept refrigerated; in clinical trials both led to about a 15% reduction in body weight in 16 months;

• Tirzepatide (Zepbound) in the multi-dose KwikPen only; this is a weekly injection through a pen that must be kept refrigerated; in clinical trials it led to a weight loss of 15% to 20% of body weight after 16 months. 

The Bridge program does not include two other classes of weight management medication combinations that were available before GLP-1s came on the market, and are available at lower cost in generic form. 

Oshman notes that a generic form of the medication Qsymia, called phentermine-topiramate, is now FDA approved; the combination has years of good evidence behind it. 

While some people cannot take it because of interactions with other drugs and health conditions, it is a low-cost option for those who must pay out of pocket, and has been shown to be effective for weight management with 10% weight loss after a year of consistent use.

There is also a pill called Contrave, which combines buproprion and naltrexone and is FDA-approved for weight management, with weight loss of up to 8% after a year. The two component drugs also have FDA approval for other purposes and are available as inexpensive generic medications, so they can be prescribed separately and taken together. Either way, though, there are some people who cannot use this option because of interactions with other medications or health conditions. 

5. There’s no requirement that participants get support for diet or exercise, or see a doctor in person 

Research using data from U-M Health’s primary care clinics shows that patients lose more weight, and sustain that loss, if they receive care guided by a provider trained in obesity medicine, and wraparound services, in addition to a prescription for a weight management medication. 

But the Bridge program doesn’t require anything other than a prescriber’s attestation that the patient is going to take the drug in conjunction with a lifestyle modification program involving diet and exercise. 

Medicare does cover Obesity Behavioral Therapy sessions with primary care providers for people with BMIs over 30, and Oshman encourages people to ask their provider if their clinic offers this or knows of a provider that does.

Oshman also notes that the Bridge program doesn’t require patients to be seen in person by the prescriber before receiving the prescription, nor that the prescriber have any relationship with the patient or experience prescribing under the Medicare system before prescribing the GLP-1 to them. 

The prescriber does not have to submit any records of the patient’s weight or height, though they do have to attest that the information on the form is true under penalty of perjury.

Oshman says, “At my office, I perform a comprehensive evaluation and create a comprehensive weight management plan before prescribing any medication. My prior authorization team submits the attestation and your medical records to the Bridge program for review after the prescription is submitted.”

6. There’s no backup plan for shortages or side effects

The high demand that Oshman predicts for the Bridge program might lead to shortages of the covered products for Medicare enrollees and others. 

But while people who get their GLP-1s through self-pay programs or other kinds of insurance might be able to switch products, the limited products in the Bridge program mean Medicare participants will have fewer options if manufacturers can’t keep up. If they miss more than two weeks’ worth of doses, they may have to start all over again at the base dose.

Also likely, she said, is that some of those who are new to GLP-1s under the Bridge program will experience what 10% or more of all GLP-1 users run into: nausea, vomiting, diarrhea and other gastrointestinal side effects that cause them to discontinue using the drug or taper their dose. 

So it’s important for those starting on the drug to understand how their prescriber will monitor their weight loss and side effects, how they should report issues and weights, and more. 

“Your clinician is doing a disservice to you if they’re prescribing a GLP-1 to you without also monitoring your weight and health goals, and any side effects you experience,” she said. “Primary care clinics are overwhelmed with patient portal messages, so it’s important to understand what kinds of follow-up appointments you’ll need, and how to escalate concerns.”

With no non-GLP-1 options available through Bridge, those who can’t tolerate any of the covered medications should talk with their prescriber about non-GLP-1 options that they could potentially pay for out of pocket. 

Those with a BMI of 35 or over may be eligible for bariatric surgery covered by Medicare.

7. GLP-1s are a long-term weight management solution; Bridge is not

People starting on a GLP-1 medication must be counseled that they are likely going to have to take some form of a GLP-1 drug for the rest of their life, or at least for many years, depending on developments in pharmaceuticals, Oshman says. 

This is not something that people widely recognize. 

“This is a long-term commitment, not a jump-start fad diet,” she said.

For 90% of patients, going off of a GLP-1 usually means rapid regaining of lost weight and reversal of health benefits. The biological effect of the drugs on appetite, metabolism and other body processes only last as long as they are in a person’s system. 

While the Medicare system is developing a successor to the Bridge program to start in January 2028, called Balance, it doesn’t yet have Congressional funding. It may also mean a new system for getting or maintaining access to the drugs for Medicare enrollees after that date.  

While individual enrollees will look at their own bathroom scales to judge whether Bridge coverage of GLP-1 drugs is working for them, Congress may want more data to determine the program’s future.