By Leanna Coy, FNP BC
In 2003, Congress made changes to Medicare. The Prescription Drug, Improvement, and Modernization Act barred weight loss medication coverage. This came on the heels of diet pill problems, such as fen-phen, in the 1990s. GLP-1 medications (glucagon-like peptide-1 receptor agonists) are now widely used for weight loss with science-backed benefits.
This has prompted the new short-term Medicare GLP-1 Bridge project from the Centers for Medicare and Medicaid Services (CMS). The project’s goal is to determine whether changes to Medicare Part D payments could improve health costs.
The program starts July 1, 2026, and runs through December 31, 2027. Medications covered under this program include Foundayo (oral tablets), Wegovy (injection and tablets), and Zepbound KwikPen (injection). The cost for these medications is a flat $50 monthly copayment. The GLP-1 Bridge project is operating outside of the standard Part D benefit. Copay for these medications doesn’t count toward a patient’s annual out-of-pocket spending cap.
Healthcare costs are one of the biggest concerns for older adults. Limited incomes and rising healthcare costs put pricey medications, like the GLP-1s, out of the reach of many. Without insurance coverage, the average cost of a GLP-1 medication can run as high as $1,500 a month. The drug companies recognize this, and some offer discount programs with direct-to-consumer options. But often, these are still too costly for the average consumer. The GLP-1 Bridge project aims to change that.
Why This Matters for Chronic Health Issues
Obesity is a growing problem worldwide. Chronic health issues, including hypertension, diabetes, heart disease, and stroke, relate to obesity. Older adults living with these conditions are at risk for a loss of physical well-being and independence. Weight loss can change that. Users of GLP-1s have significant weight loss, averaging 15% to 20% of their total body weight.
Besides weight loss, GLP-1 medications are shown to lower those health risks. There is evidence of reduced stroke and heart attack risk by about 20% in people at high risk. Studies show improved control of blood pressure, cholesterol, and decreased chronic kidney disease. The drugs also reduce inflammation throughout the body, which can lower the risk of dementia, arthritis, and sleep apnea.
Who is Eligible for the Medicare GLP-1 Bridge Program
Not everyone will qualify for these medications. The program’s purpose is only to lower obesity and the associated health risks. CMS is using body mass index (BMI) to determine obesity. Patients using the GLP-1 medications under this program are expected to also work on a healthy diet and exercise. Eligible patients must be age 18 or older and meet one of the following requirements to qualify:
- Have a body mass index (BMI) of 35 or higher.
- Have a BMI between 30 and 34.99 AND have at least one of these health conditions:
- Prediabetes
- High blood pressure that is not controlled
- A history of a heart attack or stroke
- Diastolic heart failure (heart failure with preserved ejection fraction)
- Chronic kidney disease stage 3a or worse
- Symptomatic peripheral artery disease (blocked arteries in arms or legs)
- Have a BMI between 27 and 29.99 AND have at least one of these health conditions:
- Prediabetes
- A history of a heart attack or stroke
- Symptomatic peripheral artery disease
Patients who don’t qualify for the GLP-1 Bridge program are those who are currently on GLP-1 drugs through their Medicare Part D plan. Also excluded are patients who want the GLP-1s to manage their type 1 diabetes, sleep apnea, or fatty liver disease, but don’t meet the above requirements. Instead, they may qualify for coverage under their Medicare Part D plan outside of the GLP-1 Bridge program.
How to Get Started
The GLP-1 Bridge program is available nationwide. If you are curious about treatment, schedule an appointment with your healthcare provider. They can let you know if you’re eligible, and discuss the risks and benefits of the medications with you. If your provider prescribes the medication for you, they must submit the prescription to CMS for prior authorization. Remember, Medicare is different from Medicaid, which is the Oregon Health Plan (OHP). OHP does not cover GLP-1 drugs for weight loss.
