Medicare has never been allowed to pay for a drug used for weight loss, but a temporary program that opened July 1 changes that.
Patients who qualify pay $50 a month for GLP-1 drugs. According to Medicare, the program covers the Foundayo tablet, Wegovy as injection or tablet, and the Zepbound KwikPen. Single-dose Zepbound vials and pens are not included.
Eligibility starts with a body mass index of 35 or higher, measured when treatment began. Lower numbers can qualify with certain conditions — 30 with uncontrolled high blood pressure or stage 3a kidney disease, or 27 with prediabetes, a heart attack, or stroke.
The $50 does not count toward a Part D deductible or out-of-pocket limit, Extra Help cannot reduce it, and it cannot be spread across the year through the Medicare Prescription Payment Plan.
A doctor sends the prescription and files a prior authorization. Approved patients get a letter in the mail, and the authorization holds through December 31, 2027.
According to Medicare, adults are not eligible for the new GLP-1 Bridge program if they have type 2 diabetes, moderate-to-severe sleep apnea, or advanced fatty liver disease. Anyone already getting a GLP-1 through a Part D plan is also excluded.
The reason is a quirk in the law. Medicare is barred from covering drugs used for weight loss, but not drugs used to treat a disease. People being treated for diabetes, sleep apnea, or liver disease have a route to these drugs through Part D. The Bridge exists for people whose only reason to take the drug is weight.
The Bridge is not part of a Part D drug plan, so there is nothing to shop for during Open Enrollment. For anyone who qualifies, the drug plan does not matter. For those excluded because a doctor is treating one of those other conditions, the Part D plan matters enormously — the drug has to appear on that plan's formulary. If it does not, the patient pays the full retail price, and none of it counts toward the annual out-of-pocket limit. Checking the formulary is worth doing before Open Enrollment closes.
Rick Good spent ten years in the newspaper business, including with The News & Observer (Raleigh, NC) and The Greenville News (Greenville, SC). He co-wrote, with Melinda Coleman, Rutledge to Riley: Governors of South Carolina, 1776–Present (Published by The Greenville News), and is the author of Mind Games Trivia #1 (Amazon). He has recently spent 15 years creating original trivia content through Sounds Good Mobile Entertainment and continues that with his new company, SGME Software. He edits The Smart Reader’s money, real estate, and business coverage.
