Medicare's New GLP-1 Program: Do You Qualify?

Under a new pilot program, Medicare beneficiaries may be able to obtain certain GLP-1 medications for weight loss and weight management for $50 per month if they meet eligibility criteria.

While beneficiaries must be enrolled in a Part D plan to qualify for the GLP-1 Bridge program, it will be run separately by the Centers for Medicare and Medicaid Services. As a result, the $50 monthly copay will not count toward enrollees' deductibles or out-of-pocket maximums.

The pilot, which will run through Dec. 31, 2027, is designed for individuals who can benefit from weight loss but do not have type 2 diabetes.

Eligibility

The GLP-1 Bridge is for Medicare beneficiaries who cannot get GLP-1 coverage through their Part D plan for weight management.

Patients will have access to three drugs:

• Foundayo (oral tablet)

• Wegovy (injection and tablets)

• Zepbound (KwikPen only)

All three drugs must be prescribed to reduce excess body weight and maintain weight loss.

To access the GLP-1 Bridge, patients' health care providers must submit a prior authorization request to the program clearinghouse.

Eligibility has two parts: plan type and clinical criteria.

Plan types — Only enrollees in certain plan types will have access to the program, including those enrolled in:

• Standalone Part D plans

• Medicare Advantage plans with a Part D component

• Special needs plans

• Dual eligibles enrolled in eligible plan types

Clinical criteria — Enrollees will need to have:

• A body mass index of 35 or above.

• A BMI of 30 or higher with at least one weight-related condition, such as heart failure, uncontrolled hypertension, or chronic kidney disease stage 3a or above.

• A BMI of 27 or higher with a diagnosis of at least one of the following: prediabetes (as defined by American Diabetes Association guidelines), prior myocardial infarction (heart attack), prior stroke, or symptomatic peripheral artery disease.

Anyone with a BMI below 27 does not qualify.

Caveats

The GLP-1 Bridge is the primary payer and will not coordinate benefits with Part D plans. Because the program operates outside Part D, Part D insurers are not involved in claims adjudication for GLP-1 Bridge-covered fills.

Beneficiaries may be disqualified from the GLP-1 Bridge if they have:

• Type 2 diabetes

• Cardiovascular disease, and the drug is being prescribed to treat it

• Moderate-to-severe sleep apnea

• Non-cirrhotic metabolic dysfunction-associated steatohepatitis, or MASH, with moderate-to-advanced liver fibrosis

If you have questions about your coverage, please give Alanda Dyer a call.

Phone: 951-297-9052

Email: alanda@adyerinsurance.com