The $50 GLP-1 Bridge: How to Get Affordable Weight Loss Medicines Starting July 1
Starting July 1, eligible Medicare recipients will be able to get weight loss drugs for $50 a month through the new Medicare GLP-1 Bridge program. However, most beneficiaries will not be eligible. To see if you do, read on.
The combined drugs, Foundayo, Wegovy, and Zepbound KiwiPen, have not only helped patients shed pounds, but also helped them lose money. Prescriptions can run thousands of dollars a month.
Accessibility and Health
“These treatments are major medical advances, but too many seniors currently do not have access to them because of high costs,” said CMS Director Dr. Mehmet Oz. “The Medicare GLP-1 Bridge is game-changing by making these medications more accessible and affordable, while furthering our broader mission of helping Americans live healthier lives.”
Whitney Stidom, vice president at eHealth, a consumer health insurance marketplace, is on board.
“For more than 60% of Americans age 65 and older who are overweight or obese, GLP-1 drugs could be a game changer,” Stidom reports. “But for many Americans, the high cost of these drugs is a barrier to use, including limited access through Medicare programs.
“A recent study found that 50% of Medicare beneficiaries would be interested in taking GLP-1 weight loss medications if they were covered by Medicare, so it is likely that many enrollees will be interested in entering the new GLP-1 Bridge program.”
Common Misunderstandings
Dr. James Chao, MD, FACS, The Chief Medical Officer and Founder of VedaNu Wellness, says many people miss the fine print of this program.
“But here are the people who are missing out,” Chao told SavingAdvice. “The savings apply to the weight management versions of the drugs (Wegovy, Zepbound), not Ozempic or Mounjaro which are well known for diabetes. In fact, what makes people think that the national headlines apply to them in the same way. The eligibility of this program really depends on whether your diagnosis and BMI qualify.”
Who Eligible for the Medicare GLP-1 Bridge
To be approved for the Medicare GLP-1 Bridge plan, you must be enrolled in Medicare Part D or a Medicare Advantage plan that includes prescription drug coverage. However, you also need to meet these other criteria:
- Your body mass index (BMI) is 35 or higher.
- Your BMI is 27 or higher, and you have at least one qualifying medical condition. That includes:
- Heart disease or history of stroke;
- Prediabetes;
- Hypertension that is not controlled by treatment;
- Advanced kidney disease;
- Heart failure.
Your BMI is a measure of body fat based on your height and weight.
Based on program criteria, the Kaiser Family Foundation (KFF) estimates just that one in four Medicare beneficiaries will qualify for this program.
Prior Authorization Required
Approval for one of the covered weight loss medications is unlikely, even if you meet the plan’s criteria. Your doctor must submit a pre-authorization application confirming that you meet the eligibility requirements.
Part D plans sometimes require prior authorization, but only for very expensive, high-risk, or specialty drugs. Under those circumstances, the Part D insurer approves or denies such requests. The Bridge Plan will send applications for prior authorization through its designated processor, Humana, instead of Part D plans.
Certain conditions, usually treated with Bridge drugs, are not approved under the Bridge program. The prior authorization form requires your doctor to rule out patients with type 2 diabetes, obstructive sleep apnea, and noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH)
“Beneficiaries with this diagnosis are eligible for GLP-1 through their Part D plan and are therefore not eligible for it through the Medicare GLP-1 Bridge, even if they otherwise meet the clinical criteria for the Medicare GLP-1 Bridge,” according to the report. CMS provider site.
How These Changes Affect Out-of-Pocket Costs
The $50 a month payment for those who qualify will be money for many beneficiaries. Although that payment won’t apply to the annual Part D deductible or out-of-pocket expense, which is currently $2,100.
“However, that would sound practical, still a significant savings for patients who pay a total of $975 to $1,050 today,” Chao noted. “The caveat here is to get your medication approved before your current supply runs out. If you have a month of oral supplies left when you apply, for example, you’ll want to put in a refill to use that up first.”
What If You Are Not Eligible for Medicare GLP-1?
For those without a Part D plan, there are still steps you can take to reduce your costs.
“If you don’t qualify for Medicare’s Bridge, builder savings plans are still available, as well as options to switch to a different GLP-1 covered by your plan or talk to your doctor about cheaper alternatives,” says Chao. “None of this is guaranteed, and it all depends on finding a medication that you can take medically, which is why I lead by talking to your doctor. In particular, if you are close to the BMI limits or a diagnosis, you may want a written record from your doctor that you do or do not qualify to go to the Bridge before July 1, not a quick conversation after that.”
GLP-1 temporary bridge
The Bridge Program runs from July 1 to December 31, 2027. So, millions of adults who started GLP-1 medications under the Bridge could be priced out of their access afterward.
The Bridge Program is only a temporary stopgap. CMS is buying time to develop a permanent program called the BALANCE Model (Better Ways of Living and Eating for Whole Health). The idea is that BALANCE will be in place by early 2028, permanently embedding GLP-1 coverage in Medicare.
The first attempt to launch BALANCE ended in April there plan did not receive adequate support for Part D health insurance. Many who refused to participate cited uncertainty about the cost and long-term side effects of the drugs.
In response to BALANCE’s proposal in December, i Alliance of Community Health Plans (ACHP) recommended the use of GLP-1 drugs as part of a systematic approach to weight loss. However, it had reservations about the CMS proposal.
“At the same time,” ACHP said in a written statement, “the research has raised concerns about side effects, risks, and adherence. In several studies, patients stopped taking GLP-1s within the first year and, in the process, lost significant muscle mass.
“We appreciate the Administration’s commitment to this aptly named, voluntary BALANCE coverage model for GLP-1s in Medicare and Medicaid. We look forward to seeing more details, including costing health plans.”
You May Need to Change Part D Plans
Uncertainty about the continuation of the GLP-1 drug program under BALANCE suggests the possibility that the beneficiary will start using covered weight loss drugs in July and be removed from them by the end of 2027. That may lead to rapid weight gain, according to a report published by the National Institutes of Health.
Even if the BALANCE model starts on schedule, you may need to change your Part D coverage to qualify. It is also important to note that there is no requirement for a Part D plan to participate in BALANCE. Changing plans should be done with caution, because the new plan may not include other drugs you are taking.
How Should Patients Prepare for July 1st?
Chao recommends confirming with your doctor that you and your medications qualify for the Bridge program. Some situations can be difficult. For example, Zepbound KiwiPens qualify, but other Zepbound formulations, such as bottles and other pens, do not.
“Get your health records together. Make an appointment to see a doctor before the end of June,” Chao said. “Oh, and by the way, make sure your prescribing physician is ready to submit that pre-authorization to the CMS central processor ASAP. Patients who do this will buy themselves weeks of flexibility while the rest of the pharmacy and backend processes are fixed.”
Are you currently taking GLP-1, or want to start? How will the Bridge program affect your access to medicine? Share your thoughts in the comments below.
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