Beginning July 1, some Medicare patients will, for the first time, be able to get GLP-1 medications for weight loss with a $50 monthly copay through a new affordability initiative.
The pilot, known as Medicare GLP-1 Bridge, is intended to broaden access to weight-loss treatments from Eli Lilly and Novo Nordisk, including Zepbound, Foundayo and Wegovy.
Juliette Cubanski, vice president and director of Medicare policy at the health care research nonprofit KFF, said the move does not amount to a permanent change in Medicare law. “Medicare is not changing the law right now,” Cubanski said. “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.”
The initiative is notable because it is the first time Medicare will contribute to the cost of drugs prescribed specifically for obesity. Until now, coverage for GLP-1 medications has generally been tied to other approved conditions, such as diabetes or cardiovascular disease. Although drugmakers have lowered out-of-pocket costs in recent months, many patients are still paying roughly $350 per month.
Coverage under the Bridge program is set to run from July 1, 2026, through December 31, 2027. Once that 18-month trial period ends, patients could again lose Medicare coverage for GLP-1 drugs used for weight loss unless the Centers for Medicare & Medicaid Services extends the program or Congress changes the law, Cubanski said. She also noted that manufacturers could choose to reduce their direct-to-consumer prices to align with the $50 copay.
“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.
Who is eligible?
Medicare beneficiaries who have Part D coverage and are enrolled in an eligible plan will be able to receive coverage through the Bridge program.
To qualify, a provider must submit a prior authorization request confirming that the patient is being prescribed a GLP-1 medication for weight loss. Prior authorization is the approval process that allows a pharmacy to fill the prescription under the plan’s coverage rules.
Providers must also demonstrate that their patient meets certain clinical criteria related to their body mass index (BMI) and health conditions when they first start taking a GLP-1. They must either have:
- BMI of at least 35
- BMI of at least 30 plus a history of heart failure, uncontrolled hypertension or chronic kidney disease
- BMI of at least 27 plus prediabetes, a previous heart attack or stroke, or symptomatic peripheral artery disease.
Patients are not eligible for coverage through the Bridge program 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.
KFF estimates 3.8 million Medicare beneficiaries will meet the coverage eligibility requirements.
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“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.
What drugs will Medicare cover?
Eli Lilly’s Foundayo, a daily weight-loss pill, as well as Zepbound KwikPen, a weekly weight-loss injection, are covered, along with Novo Nordisk’s Wegovy weight-loss medication in both injection and pill forms.
How much will I have to pay?
Medicare recipients who meet the eligibility requirements will have to pay a $50 monthly copay to access the GLP-1 drugs. However, there are a few things to keep in mind. Because the program is being offered outside Medicare Part D coverage, the copay doesn’t count toward a patient’s deductible or yearly out-of-pocket cap.
“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.”
In addition, patients aren’t allowed to apply coupons or discounts to further reduce the price.
Aimee Picchi
