Medicare covers GLP-1s for weight loss starting today -- info on prior auth and eligibility
Medicare just started covering GLP-1s for $50/month through a new program called Bridge. It goes from today (July 1) to the end of 2027 (another GLP-1 program, BALANCE, is anticipated to start after that). Here's some info about which patients are eligible, and what needs to happen to actually get GLP-1s covered for your patients.
All patients with BMIs of 35, and some patients with BMIs 27-35, have coverage, so long as their Medicare Part D plan wouldn't normally cover a GLP-1 (more on that in a sec). Patients with a BMI of 27-35 are eligible if they have other chronic conditions or medical history in this table:
| Patient BMI | What else they need |
|---|---|
| 35 or higher | Nothing else required |
| 30 or higher | Heart failure with preserved ejection fraction, uncontrolled high blood pressure, or chronic kidney disease (stage 3a or higher) |
| 27 or higher | Pre-diabetes, a prior heart attack, a prior stroke, or symptomatic peripheral artery disease |
Medicare Bridge covers Foundayo tablets, Wegovy as an injection OR tablets, and Zepbound.
- Single-dose Zepbound pens and vials are NOT covered.
To get coverage, the patient's physician needs to submit a prior authorization form. You can download the PDF directly from Medicare here or use this Medicare GLP1 prior auth PDF form filler to generate a PDF ready for signing. The form itself has various questions about the patient that correspond to the eligibility criteria above. Note that before submitting this form, the pharmacy should submit a claim which is denied.
A few more notes on eligibility, edge cases, operations, etc:
- You don't actually have to be enrolled in Medicare to prescribe your Medicare patients GLP-1s, but you can't be on the Preclusion List.
- Medicare Part D coverage. Some patients were already eligible for GLP-1 coverage through Medicare Part D. If that's the case, they're not eligible for Bridge. However, there is a new cost cap of $2,100 per year for Medicare Part D, so your patients in this category do have cheaper access to GLP-1s than before (even if the out of pocket cost is higher than most of us would like). Medicare Part D covers GLP-1s for T2D, moderate-to-severe sleep apnea, or MASH; for those patients, the pharmacy submits claims directly to the Part D plan as usual and nothing changes.
- Prior auth claims can be submitted starting today, July 1. Medicare says you'll hear back within 72 hours.
- After the prior auth is is approved, subsequent fills don’t require a new prior auth (unless you change the patient to a different medication). Only 28-day or 30-day fills are covered under Medicare GLP-1 Bridge for now.
Medicare has more official documentation here, but the above covers the basics and I hope it's helpful!
