New Medicare Bridge Program Covers Weight-Loss Drugs For Some Patients

For years, Medicare has generally been barred from paying for prescription drugs when they are used specifically for weight loss.

A temporary program that began July 1 changes that for some beneficiaries.

The GLP-1 Bridge program gives eligible Medicare patients access to certain weight-loss medications for $50 a month. According to Medicare, it covers Foundayo tablets, Wegovy injections or tablets, and the Zepbound KwikPen. Single-dose Zepbound vials and pens aren’t included.

The $50 monthly payment is separate from Medicare Part D. It doesn’t count toward a Part D deductible or annual out-of-pocket limit, Extra Help cannot reduce it, and patients cannot spread the payments throughout the year through the Medicare Prescription Payment Plan.

Who Qualifies?

Eligibility is based partly on body mass index, or BMI, measured when treatment began.

A BMI of 35 or higher can qualify a patient. People with lower BMIs may qualify if they have certain health conditions.

A patient with a BMI of at least 30 may qualify with uncontrolled high blood pressure or stage 3a chronic kidney disease. The threshold drops to 27 for people with prediabetes or a history of heart attack or stroke.

A doctor must prescribe the medication and submit a prior authorization request. If approved, Medicare sends the patient a letter.

The authorization remains valid through Dec. 31, 2027.

Why Some Patients Are Excluded

The Bridge is designed for patients seeking GLP-1 medication specifically for weight management. Some people with other medical conditions may instead have a route to the drugs through Medicare Part D.

According to Medicare, adults aren’t eligible for the Bridge if they have Type 2 diabetes, moderate-to-severe sleep apnea, or advanced fatty liver disease. People already receiving a GLP-1 through a Part D plan are also excluded.

This is because of how Medicare law treats weight-loss drugs.

Medicare has historically been prohibited from covering drugs when they are prescribed specifically for weight loss. That restriction doesn’t necessarily apply when the same medication is approved and prescribed to treat another covered disease.

As a result, someone taking an eligible GLP-1 specifically for obesity may qualify for the Bridge, while a patient receiving a GLP-1 to treat a condition such as Type 2 diabetes may receive coverage through Part D.

That difference matters most during Medicare Open Enrollment.

The Bridge isn’t part of a Part D prescription drug plan, so eligible beneficiaries don’t need to shop for a Part D plan that includes the Bridge benefit.

However, for patients receiving a GLP-1 through Part D, plan choice can make a substantial difference.

Each prescription drug plan has a formulary, or list of medications it covers, and costs and restrictions can vary among plans. Patients expecting to receive a GLP-1 through Part D should check whether the plan covers their medication and what coverage requirements apply.

If a drug isn’t covered and the patient pays the full retail price, those payments generally don’t count toward the Part D annual out-of-pocket limit.

For beneficiaries using Part D rather than the Bridge, checking that coverage before Open Enrollment closes could prevent an expensive surprise.