Millions of Medicare beneficiaries may soon pay significantly less for popular GLP-1 medications under a new federal pilot program, called Medicare GLP-1 Bridge, that began July 1.
The demonstration project expands Medicare coverage for certain beneficiaries with obesity and prediabetes who are prescribed GLP-1 drugs such as Wegovy, Zepbound and Foundayo. Eligible participants who previously paid around $350 a month out of pocket could now pay a $50 copay instead.
The initiative represents one of the most significant changes to Medicare’s approach to weight-loss medications in years. It also serves as a test of whether expanding access to these drugs can improve health outcomes while reducing long-term healthcare spending.
[READ: Supplements for GLP-1 Users: Essential Vitamins, Protein and Side Effect Relief]
Who Is Eligible for the New Medicare Coverage?
The pilot program is available to certain Medicare beneficiaries who meet the program’s eligibility requirements, including:
— A body mass index, or BMI, of at least 27, as well as prediabetes, a previous heart attack or stroke or symptomatic peripheral artery disease.
— A BMI of at least 30, as well as chronic kidney disease, a history of heart failure or uncontrolled hypertension.
— A BMI of at least 35.
The initiative operates under Medicare’s research and demonstration authority, allowing the federal government to temporarily test new coverage models without permanently changing Medicare law. The program is scheduled to run through 2027 while officials evaluate its impact on patient health and overall Medicare spending.
The expanded coverage includes certain GLP-1 medications approved to treat obesity, including Wegovy, Zepbound and Foundayo. Beneficiaries who qualify could see their monthly prescription costs drop substantially, from about $350 to a $50 copay.
[READ: 5 Heart Health Numbers You Should Know]
Why Medicare Is Testing Expanded GLP-1 Coverage
For more than two decades, Medicare has generally been prohibited from covering medications prescribed solely for weight loss.
Congress enacted the restriction in 2003, citing safety concerns surrounding earlier generations of weight-loss drugs as well as concerns over the potential cost to the Medicare program. Since then, however, GLP-1 medications have emerged as a newer class of drugs that studies have shown can produce significant weight loss while also improving other health outcomes for many patients. According to a recent Healthcare Pulse Survey conducted by eHealth, 39% of respondents said they would be interested in trying a GLP-1 drug if it were covered by Medicare.
“Hopefully history will reflect this — Medicare’s commitment to prevention–health promotion rather than all sick care,” says Dr. Annie Moore, professor of clinical medicine at the University of Colorado Anschutz Medical Center.
Federal officials estimate the pilot program will cost between $2.5 billion and $4.4 billion annually. Supporters argue that broader access could help prevent or delay chronic conditions such as Type 2 diabetes and cardiovascular disease, potentially reducing healthcare costs over time.
“It is not really a ‘trial’ or temporary in that it is going to transition in 18 months into the BALANCE program,” says Moore, “which is a total of five years — this length of time will hopefully provide some budget neutrality with cost savings to offset the cost of the medication.”
[READ: Prescription Weight Loss Drugs: Which Weight Loss Drug Is Best?]
What the Program Could Mean for Beneficiaries
The launch comes as demand for GLP-1 medications continues to grow among older Americans.
According to the Healthcare Pulse Survey, many Medicare-eligible adults say prescription drug affordability remains one of their biggest healthcare concerns. Lower out-of-pocket costs could make these medications more accessible for beneficiaries who previously found them financially out of reach.
Still, not everyone taking a GLP-1 drug will qualify for the new benefit. Medicare beneficiaries using these medications solely for weight loss outside of the pilot program generally remain subject to existing coverage rules.
“I think the other major concern is that the ‘sickest’ patients are disqualified,” says Moore. “This is particularly true for those with moderate to severe sleep apnea or Type 2 diabetes, that will now be faced with the $2,400/year charge (deductible for Medicare medications) versus the $600/year cost of the Bridge program.”
Beneficiaries interested in the new coverage should check with their Medicare Advantage or Part D prescription drug plan, as well as their healthcare provider, to determine whether they meet the pilot program’s eligibility requirements and whether their prescribed medication is included.
While the demonstration program is temporary, its results could help shape future Medicare policy as lawmakers and federal health officials continue debating whether weight-loss medications should play a larger role in preventing chronic disease among older Americans.
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Medicare Is Now Covering Some GLP-1 Weight-Loss Drugs for $50. Here’s What Beneficiaries Need to Know originally appeared on usnews.com
