Medicare To Offer GLP-1 Obesity Drugs At Flat Monthly Rate: What To Know

Starting in July, some Medicare beneficiaries will be able to access GLP-1 medications by paying one flat fee per month. The temporary program is set to run for a year-and-a-half through the end of 2027.

But with less than two weeks before its launch, questions remain over how it will operate.

The Medicare GLP-1 Bridge, described by the Centers for Medicare and Medicaid Services (CMS) as a “time-limited demonstration,” will officially run from July 1, 2026, to Dec. 31, 2027.

Announced in December, the program will allow eligible Medicare Part D enrollees to access GLP-1 medications for a $50 monthly copay. Despite GLP-1s being indicated for diabetes, obesity and some heart conditions, the Bridge program will almost solely be available to beneficiaries seeking weight management solutions.

The program is meant for Medicare beneficiaries who do not have a medically coverable indication for GLP-1s through Part D coverage. Federal law currently prohibits Medicare from covering weight loss medications.

Organizations like the Obesity Care Advocacy Network (OCAN) have praised the program, with OCAN Coordinator Cristy Gallagher calling it a “historic milestone in the fight against the obesity epidemic.”

There are some regulatory observers, however, who have concerns over how the program will be administered. And there are lingering questions over how much this will cost. Bob Herman of Stat News reported earlier this month that inquiries to CMS about the cost of the 18-month program have not been answered.

The Hill also reached out to the Department of Health and Human Services for information on the program’s cost.

How it works

According to CMS, the program won’t require Medicare enrollees to fill out any additional paperwork or take any further steps past getting a prescription from their doctor.

In order for a beneficiary to join the program, a medical provider must submit a prior authorization request and a prescription for one of the eligible GLP-1 medications.

The medications that will be covered in the program include Wegovy, Zepbound and Foundayo. If a patient begins on one of these medications and switches to another in the middle of the Bridge program’s duration, they will need a new prior authorization form.

When the provider sends the prescription to a pharmacy, a pharmacist will then route that prescription to the Bridge program’s central processor, which CMS is referring to as the Bridge PCN.

Aurelia Chaudhury, co-lead of CMS’s Cell and Gene Therapy Access Model, said in a webinar hosted by obesity groups, including OCAN, that her agency will not be processing prospective prior authorizations, which are done at the time of prescribing. If the patient’s prescription issued for the Bridge program is their first GLP-1 prescription, the claim will be rejected before a prior authorization form is sent to the issuing provider.

The prior authorization form will ask physicians to attest that their patient does not have Type 2 diabetes, moderate to severe obstructive sleep apnea or MASH fatty liver disease.

Claims will not be processed before July 1.

“The Medicare GLP-1 Bridge seeks to test whether providing access to GLP-1 products at a uniform CMS negotiated net price will help improve beneficiary outcomes and reduce long-term Medicare spending,” Kelly Strachan, CMS health insurance specialist and Innovation Center fellow, said in the webinar.

The monthly $50 copay will not count toward a patient’s deductible or maximum out-of-pocket costs.

When asked what the plans are for the Bridge program at the end of 2027, Chaudhury said, “We understand that there’s a lot of interest from patients in understanding what’s going to happen after December 31st of 2027. We are looking forward to sharing more information as soon as we can on Medicaid.”

Who is eligible

To be eligible, beneficiaries must enroll in either a standalone prescription drug plan or Medicare Advantage coordinated care plan. CMS lists those enrolled in Special Needs Plans, employer/union group waiver plans and the Limited Income Newly Eligible Transition program as also being eligible to participate.

Beneficiaries of Tricare For Life, the Medicare-wraparound coverage for military retirees and dependents, can also access the Bridge program, but they must also be enrolled in an eligible Part D plan type. Dual enrollees in both Medicare and Medicaid can also be eligible.

Catherine Varney, an obesity medicine physician and trustee at the Obesity Medicine Association, was asked during OCAN’s webinar to describe the ideal patient to benefit from GLP-1 Bridge.

“Those at greatest risk of obesity and obesity-related diseases,” said Varney. “We know that obesity is not a benign disease … it’s associated to over 200 chronic conditions and 13 different types of cancers.”

Qualifications will vary based on the patient’s body mass index (BMI), and there is a minimum BMI to be eligible.

Beneficiaries must be at least 18 years old and have a BMI of 27 or higher and must also be diagnosed with at least one of the following conditions: prediabetes, a previous myocardial infarction, a previous stroke or a symptomatic peripheral artery disease.

Those with a BMI equal to or greater than 30 must also be diagnosed with heart failure with preserved ejection fraction, uncontrolled hypertension or chronic kidney disease stage 3a or above.

Patients with a BMI of 35 or greater do not require an additional diagnosis to participate in the Bridge program.

Regulatory concerns

Strictly speaking, the Bridge program is operating outside the normal scope of Medicare, which is prohibited from covering medications solely indicated for weight loss. By opening up Medicare to obesity medicine prescribers, some worry that the program could introduce potential avenues for fraud or misuse.

Christopher Frisina, healthcare regulatory counsel at the law firm Alston & Bird, noted that many people get telehealth visits that are considered sufficient to obtain a prescription eligible for the Bridge program.

“I think maybe that this GLP-1 Bridge program might inspire new telehealth providers or existing telehealth providers that to this point haven’t taken Medicare reimbursement to move into this space,” Frisina told The Hill. “And it’s a risky place, because Medicare requires more diligence in business practices than a lot of businesses do.”

Frisina acknowledged that CMS appears to have done its due diligence in setting up the demonstration program but cautioned that fraud is always a possibility.

“It requires the provider to fill up this really detailed prior authorization form to send that in before approval can happen. So, you have a check and balance that requires the coordination between two different entities — the provider and the pharmacy — to actually get the fraud,” he said. “It’s not going to be as straightforward as some of the fraud schemes that we often see, but I don’t think it’s outside of the realm of possibility.”

When it comes to how much the demonstration will cost, CMS has not given a clear picture.

“CMS has not publicly released cost estimates or enrollment projections for the Medicare GLP-1 Bridge demonstration model,” an agency spokesperson told The Hill.

“Under the Medicare GLP-1 Bridge, eligible Medicare Part D beneficiaries will have a $50 copay per monthly supply of an eligible GLP-1 drug,” they added. “Because the demonstration operates outside of the Medicare Part D benefit’s coverage and payment flow, it does not follow the standard Part D structure for cost-sharing, deductibles, or out-of-pocket accumulation.”

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