July 1 will usher in an important change in Medicare Part D and access to the treatment of obesity as a chronic disease.

Despite our new understanding of obesity and the development of effective therapeutic agents, a statutory loophole has long blocked Medicare Part D from covering weight-loss medications, leaving vulnerable older patients at increased risk of heart disease, stroke, and many other conditions for which obesity is a known risk factor. Despite the widespread availability of these medications, they remained financially “out of reach” for many patients.

With the launch of the Medicare GLP-1 Bridge program on July 1, Medicare patients will be able to access these therapies with a copay of $50 per month. This landmark program is an important advance for health equity and chronic disease management.

It is important to note that the Bridge program operates outside the standard Medicare Part D payment system, so practitioners cannot simply e-prescribe these medications the way other medicines are administered.

Here are the program rules:

Eligibility:

  • Patients must have Medicare Part D or Medicare Advantage.
  • Patients who are not on GLP-1s must have one of the following:
    • A BMI of 35 or higher for weight management alone
    • A BMI of 30 with severe comorbidities like uncontrolled hypertension or heart failure
    • A BMI of 27 alongside conditions like prediabetes or a history of stroke.

      For Patients already on GLP-1s, eligibility is tied to their baseline statistics before they started losing weight. (Note: If Medicare if already covering the GLP-1, the patient will not qualify for this program.)

Process:

Submit an approval request to the pharmacy. This is reviewed by the Medicare team. An obesity diagnosis code must be included and explicitly write “SEND TO BRIDGE FOR WEIGHT MANAGEMENT” in the prescription notes. Failing to do this will cause the pharmacy to mistakenly route the claim to Part D, leading to a rejection.

Once approved, the patient is notified. They will pay a $50 copay for each 30-day prescription. The payment is not part of Medicare Part D. This temporary, bridge program runs through December 2027.

AMWA has long advocated for better access to the treatment of obesity, an important health issue for women, given its impact on heart disease, the leading cause of death in women. Learn more about AMWA’s work in obesity here.

Resources:

AMWA is a member organization of the Obesity Care Action Network (OCAN), which has developed a wonderful tool to guide to help practitioners, patients, and pharmacists navigate this new process. The tool will be shared with AMWA members. We also welcome you to share this infographic from OCAN that details the patient journey.

CMS Resources are available here.