GLP-1 Medicare Coverage FAQ & Weight Loss Tips From Obesity Doctor

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Will Medicare finally expand access to GLP-1 medications for obesity? How do you qualify? 

In this episode, Kim and Kat are joined by community co-host Deb Cooperman and DeeDee, a 70-year-old GLP-1 patient, to discuss Medicare coverage, weight loss, maintenance, and life on GLP-1s after 60.

Deb shares her experience paying cash for treatment while hoping to qualify for the new Medicare Bridge Program. DeeDee discusses maintaining her weight loss after losing access to medication, moving to compounded treatment, and growing up in a generation shaped by diet culture.

Topics include:

• GLP-1 medications after 60
• Weight loss and maintenance
• Medicare coverage and affordability
• Diet culture and obesity
• Long-term patient tips and lessons learned
• Access to obesity treatment

Obesity medicine specialist Dr. Michael Albert joins the conversation to answer common questions about Medicare coverage and the new Medicare Bridge Program, including:

• Who qualifies
• How the program works
• How to apply
• Options if you don't qualify

He also discusses:

• Weight loss with GLP-1s in older adults
• Protecting muscle mass and prioritizing protein
• Side effects to watch for
• What to advocate for with your doctor

Whether you're on Medicare, approaching eligibility, or helping a loved one navigate obesity treatment, this episode offers practical advice, patient perspectives, and expert guidance.

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https://www.instagram.com/thedebcooperman 

https://www.instagram.com/thedebcooperman 

Follow Dee Dee

TikTok https://www.tiktok.com/@deesback  

Dr. Michael Albert

Instagram and TikTok:
 @michaelalbertmd

Website:
 MichaelAlbertMD.com

#GLP1 #Medicare #MedicareCoverage #ObesityMedicine #WeightLoss #HealthyAging #Zepbound #Wegovy

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Use Honest Care to Appeal GLP-1 Denials. Go to HonestCare.com/Kim 

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Transcript

SPEAKER_05 0:00

Welcome, welcome to the Plus Sides Podcast.

SPEAKER_04 0:02

Hi, Ken.

SPEAKER_05 0:03

Hi, bravo, bravo. Strange, Strange. We're here.

SPEAKER_04 0:11

I know. We're here. We're going to have a very good conversation today. Everybody hang with us. We've got a little bit of an internet lag with Deb. Um, but we're going to do John will do all his magic editing stuff. So everything syncs beautifully. So just give us some grace because it's an important conversation. Okay. But if you're new here, we're going to do quick intros and then you can meet our uh our uh lovely uh co-host dev that is joining us today. And um we'll talk a little bit why we're here and what we're doing, okay? Um I'm Kim and this is the Plus Sides. We are a multi-world winning podcast ranked in the top 1% of all podcasts in the world. It is a very reputable source if you were trying to learn about metabolic disease and GLP1s. Um we interview people from our community as well as experts in this field, from researchers to scientists to doctors, obesity specialists, endocrinologists, bariatric surgeons, et cetera, so that you can learn everything you need to know about why this is and how this works, because there's a lot of misinformation out there. And then also see that you can forgive yourself, you know, and realize that this isn't your fault, it's biological and um be able to, I think just be the healthiest you you can be is kind of what we're going for, you know. So that's what we do here. We talk about GLP ones, but all different stuff. We talk about lots of different things. Uh, and so just go ahead and we're glad to have you. Glad to have you. Um, menopause, yeah, I know. Fashion everything.

SPEAKER_05 1:29

Yeah, mental health. Yeah. Um, Kat, who are you? What'd you do? Why are you here? I am Kat Carter. And before we get started, uh, if you could like, if you could give us five stars reviews, you're watching. We are not watching the bag. If you're watching, click all the things. There we go. Um, we love it. We love it. We appreciate you. Subscribe, all that good stuff. Um, I'm Kat, I'm Kat Carter. You can call you can find me on TikTok, Kat Carter7, or Mrs. Kat Carter on the Instagram. Um, I keep things kind of light and fluffy. Um if I am uh Kim's light and fluffy counterpart. So if you want to get a little comic relief and some silliness, you can just come to my content. That's um that's what I do. I used to call myself the spare plus sides her because um I was a nut bar. I'm a nut bar. But I I mean I am I keep things light and fluffy for the most part. So you're all the things, Kat.

SPEAKER_03 2:26

So yeah, yeah.

SPEAKER_05 2:28

I do everything, I can go deep, but for the most part, let's keep it light and fluffy. It keeps it balance.

SPEAKER_04 2:34

She's the metal child, she balances things.

SPEAKER_05 2:36

I know, but I love it. I like being light and fluffy in despair or the Ed McMahon to uh uh Kim's Johnny Carson. Is that wait sure you know what I'm going south? I'm Kat Carter. You can find the Kat Carter on TikTok. I have lost a hundred LBs. Um, it took me three years. Um one because I'm a slow responder, and two, I refuse to give up uh a good piece of cake um and a good glass of wine. Um girl. Oh, Deb, I got Kim in trouble last week. Oh my god.

SPEAKER_04 3:12

I blame at least five pounds of my regain on her cake.

SPEAKER_05 3:17

Yeah, so I get out of the house. But that's that's me in a nutshell because I'm a nut.

SPEAKER_04 3:21

Wait a minute. I got before we do anything, I just gotta type out this cake. I can't help it. The human strong, the few noise is strong. I have to tell you this about this cake. So can I made this cake for my husband's birthday? It's a Mountain Dew cake. So it's like the whole idea of right, like a coat cake, but Mountain Dew, right? And the the icing is buttercream and it's like lime, and like I can't even. It is the best effing cake I've ever effing had. And and when I'm telling you, John, I polished off half of it, half of it. There's a big ass cake. The shame.

SPEAKER_05 3:54

So well, I said you gotta keep your big ass, right? What's it? Get an authentic butt. We don't have it. We got a big ass, big ass cake. It was worth it, worth every damn bite. That I mean, I'm saying, yeah. Remember how we used to do it though? Let's look at it. That's how I used to do it. That's what I'm saying. Remember, we would like secretly binge on it, like nobody knew half the cake was missing by the next day.

SPEAKER_04 4:17

Yeah.

SPEAKER_05 4:19

No, I let it all hang out this time.

SPEAKER_04 4:21

But it's the first time I did anything like well, and keep in mind, it wasn't all in one sitting, right? It was like two pieces.

SPEAKER_05 4:25

No, yeah, but what I yeah, but what I'm saying is, you know, at one time you could I you could I could put it away. But no, no, that's that's definitely an NSV. That is uh a blessing.

SPEAKER_04 4:35

NSV, I didn't need all of the cake all of the time. I'll take it. Right anyway, yes. All right. So, Deb, who are you? What you here, what you here for? What you doing?

SPEAKER_01 4:46

Well, I'm Deb Cooperman, and I'm um a year into my experience with uh GLP1 medication, a little over a year. And um I say I'm a a writer and a uh workshop leader and uh surprisingly now a creator on TikTok, which shocks the living everything out of me. But um I just stepped into advocacy because um as soon as I got on these medications, I knew I wanted everybody to be able to have affordable access. And so I'm I'm grateful to be able to be here to talk about what we're gonna talk about tonight because it's really important stuff.

SPEAKER_04 5:29

Very important. So Deb was on our show um a couple episodes back. Um she was kind enough to join when after my sister had passed away, and um, and we both have a connection there that she's also lost her sister. And so I was not, y'all know, my best self. I'm kind of all over the place right now, communication-wise. And we did a lovely episode where she shared her story. And I just thought that we needed to have a conversation about Medicare, the bridge program. But even more important than that, in my opinion, is um I think just this generation, right? Um, being able to discuss what this is gonna be like, right. And um, and so I I more and more people are searching, more and more people are seeking, and with the access, being able to expand soon, I think it's not just important to understand the program and what's gonna, you know, who's gonna get and who's not, right? But understand the journey, understand if you aren't like in that program, what are options that are available to you? Um, and understand as you go on it, like what you need to get from your doctor, right? Um, and what you need and what you deserve and how you can advocate for that. And that's all a lot of stuff. So we're gonna cover that today. Um, we also have our buddy Dr. Albert with us. He's gonna, he's been on the show before first season. Do you guys are all first doctor? Yes, I know.

SPEAKER_03 6:50

I still quote him.

SPEAKER_05 6:52

Yes, I'm I'm excited.

SPEAKER_04 6:55

And so that's what we're gonna do. And we have my friend uh Didi who's gonna join us as well, and her and Deb are gonna have a nice conversation. So we are so happy to have you with us. Thanks for joining. Let's get started. Okay, let's go right in, Didi.

SPEAKER_02 7:07

Hello, Dee Dee. Hi, Kat. Hi Kate. Hi, Deb. Nice to meet you.

SPEAKER_01 7:12

Yeah, what lovely to meet you too.

SPEAKER_04 7:15

Well, we're so glad to have you today. I'm gonna, Kat and I are gonna kick back just a little so you guys can talk because um one thing that I said um to Deb recently is I was like, I as much as I can say that I relate, right? That we've all gone through similar stuff with dire culture and stuff, it is different. It just is, you know. And so I want you guys to talk a little bit because I think I've interviewed both of you now, and you're very similar in terms of what you've gone through. You know what I mean? And I think um it would just be nice uh to um to connect and and and go from there. How's that sound, Deb? Good, sounds good.

SPEAKER_05 7:50

So then everybody listening can follow you. You can too. Yes, learn, right? Go.

SPEAKER_01 7:56

Yeah. All right, yeah, we're ready to go. All right, go ahead. Okay. So um, Didi, I'm I'm delighted to meet you. And um, these two have been saying that we are gonna get on great. So I'm gonna we're gonna have to work really hard to sort of stay on um where we where we want to be, because I have a feeling we could we could go all over the place. But what I really what I really want to know, um, and I think probably um anybody listening will want to know, is a little bit about what your experience was like before you found these. I and I know what we're talking about right now is the medication. So what what what was your life like before you found this medication?

SPEAKER_02 8:39

My life before the medication was a constant struggle from the age of I don't even know what age, probably 12. I don't remember. Yeah. Um was a constant struggle, either from the incoming at me, you know, you had to be thin, you had to be twiggy, you had to be share, you had to be this, you had to be that. Whether you even if you were this big, if you saw pictures of me, Deb, and I know Kim has seen them. I was this big, but I thought I was this big. Okay, and it was constant with my mother being on Weight Watchers. I mean, when cauliflower used to be popcorn, okay, you put butter salt on it and called it popcorn.

SPEAKER_01 9:28

Okay, that's how far back I go with weight.

SPEAKER_02 9:32

Was your was your mom uh a heavy person or was she my my mother dated with the my mother was a burlesque dancer, so it was her job to have a great body, but yes, obesity most likely runs in my mother's side of the family, just looking at my grandmother, okay, and looking at my aunts and everybody, and they struggled, even though they never talked about it their whole lives, and then you'll see they hit a certain point in pictures, and everybody looks like this, okay. It's just the way it was. Um, so for me, my whole life was constantly watching what I was eating, when I was eating. I mean, I before I was 25 years old, I think I had been on just about every diet they published in every teen magazine and cosmopolitan or whatever. And from there it went on. When I had my children at 35, I weighed in at 120 when I got pregnant. After I had my first daughter, I was 190 pounds. That's when it all revealed itself. Okay, the whole thing revealed itself.

SPEAKER_01 10:43

Pregnancy mucked with your hormones and the whole shang, right?

SPEAKER_02 10:46

And I got ju I got uh gestational diabetes with it. I got the whole, the whole thing. After that, I went to Weight Watchers, I got off maybe 40 pounds of it, got pregnant again, only gained 29 pounds that time. I literally didn't eat after the kids were born. I managed to through struggle, through going on fenfen, through whatever, to keep myself at 140, which for me seemed like a huge number. Okay, it seemed like a huge number. And now it probably seems like hey, that's not so bad, right? Because we because we have a number. But I mean at the time coming up in that diet culture where 105, 100 pounds, 140 was like, please. Um then menopause and a divorce, and my mother dying all hit at the same time. And guess what? My body bounced right back to 188 pounds without me blinking an eye within six months. That was about 25 years ago. Okay. At that point, it just was a continual struggle. Every day doing the things I've heard cats say, and that I've heard other people, you know, waiting till the kids go to bed to eat the rest of the ice cream or the food they left on the plate or whatever it was. It was constant, a constant struggle. And I believe probably from about 20 maybe 2010, I learned to eat no sugar, no grains. That helped me not balloon up. Oh, okay. So I managed to never go over 200 pounds ever. I could get down to 172, I could get up to 190. Okay, but rarely could I get down to like 150. But for until GLP once, I hadn't eaten sugar or greens since about 2010. And that was about the only thing that I think saved me from going to 250 pounds.

SPEAKER_01 13:00

Wow. Okay. So so was that was that a conscious choice?

SPEAKER_02 13:04

Like that was like, okay, somebody said this is a this is a diet you should try because you'll somebody uh a trainer said to me, not a trainer, yeah, a trainer, and it was a podcast. Um, a trainer put it this way, and it made sense to me. When they fatten cattle, what do they feed them? They feed them sugar pellets and grains. They shove grains down geese's throats to make a fatty liver. Oh jeez. But if you think about it, okay, and it did help with joint pain, it did help with a lot of things, taking grains in general out of my diet. Did I never eat them? No, I mean, it was 95.5. You know, I mean, if I went to a birthday party or something, or I was some, I would eat it, but I never felt good about it. I still don't use sugar consciously.

SPEAKER_01 14:00

Oh, okay, okay. Wow, okay. Um, so when what got you to like when did you find the the medication, the treatment? When did you find that?

SPEAKER_02 14:13

I believe it was in December of 23. I was diagnosed with AFib in October of 23. Um, and the first thing all the doctors said was, oh, if you could lose weight, it would help your AFib. Yay!

SPEAKER_01 14:29

Well, if I could lose weight, I probably wouldn't have AFib. I never thought of that before. Thank you so much.

SPEAKER_02 14:35

Thank you so much. And so I at that time I think I was doing the Mediterranean diet because it was heart-related and walking and walking and walking and doing all the things and nothing was working. And I heard about the Ozempic, okay, Ozimpic, and I finally Googled it and the Plus Sides podcast came up, and I sat and binged the podcast. Oh I binged the binged it, and then I immediately sent a note to my primary care doctor. I said, I need to come see you. And I went to see her in December of 23. Um, and I said, Do you think this will help me lose weight? All the you know, the electro, everybody wants me to lose weight. And she said, Yeah, I think it's gonna help you. She said, but I can't get you covered on insurance. And she was gracious enough to have had other patients who figured out ways to access the drugs via, and Kim knows this, and I can say it, through Canada. Oh Canadian pharmacy. I'm one of the first people I think you guys knew that was getting it from Canada. And um, she also knew about the compound road. Um, so she gave me those links and she said, I am not recommending it, but I have patients, I know. She was very careful about it. Yeah, and I ordered it from Canada and was on it from Canada probably three, four, five months when they passed Wagove for cardiac. Tim turned me on to Dr. Albert. Dr. Albert got me covered on Wagove.

SPEAKER_01 16:23

Okay.

SPEAKER_02 16:24

Okay, on that first year, then the insurance dissolved itself at the end of the first year, and then Dr. Albert was very helpful and always finding ways to gain access to prescription um meds for me, um, which I have availed myself of until we couldn't, till we couldn't anymore, you know, until things happened in the world that made it not doable anymore. Because the prices in Canada now are the same as the prices here. Okay.

SPEAKER_01 16:58

So are you so you are currently still taking Wagov, you're still using Wagovi?

SPEAKER_02 17:04

No, no, no, no. When I lost coverage for Wagovi, we switched me right back to Manjaro because that's where I started, and then we went to the Wagovi because I had coverage, and then when I lost the coverage, you've been like we went back. Okay, okay. And in my humble opinion, I'll take whatever they'll give me. Okay.

SPEAKER_01 17:26

Because it's is it is it it's helped with your um with your weight, and has it helped also with the um AFib?

SPEAKER_02 17:37

Oh my god, yes. Uh, and in fairness to my electrophysiology team, yes, there were ablations, okay, but they felt that the GLP1 was the missing link that helped my sleep apnea, which I didn't have a score high enough to get covered. Let's go there, okay? But I had sleep apnea. Okay. Um, that it helped that, which is a contributor. The weight obviously came down, which was a huge contributor, and then it made my ablations that much more successful. So knock on wood. We don't talk about it very much right now because I don't like to say the words, but knock on wood. I mean, I'm I'm having a good long run right now, okay? And so I always say they're going to have to pry these drugs out of my cold dead hand.

SPEAKER_01 18:29

I say the same dog, right? The same thing. You will have to, it's been a year, and as soon as that food noise went off, as soon as I felt like I had no no longer had a bottomless pit for a stomach, I was like, no, they're never going away.

SPEAKER_02 18:44

You know, my my my one daughter, Kim and Kat know this, she's a plus size influencer, and she was very anti-GLP one for a while. But then at her birthday dinner here in April, we all went to an Italian restaurant and I'm ordering pasta, and her sister who's on a GLP one's ordering pasta, we're all ordering pasta, and she goes, Those GLP ones are the best thing that ever happened to this family because we're finally eating normal.

SPEAKER_01 19:10

Right. Dee, I have a friend who saw me after I'd been on for I don't, I don't know how long it was, you know, maybe a couple of months, and she saw a difference, and so she asked me to order. And we went out to dinner and and I ordered something that you know, somebody who's on a diet is not going to eat. Correct. And she said, Can you eat that? And I said, Eurene, I can eat whatever I want. I just want less of the things I used to want, and I want less of a lot of things. And it's just so much easier to make the choices that are good for me. And I'm hearing that from you as well. That's wonderful. I'm glad you're enjoying it. It's very freeing.

SPEAKER_02 19:46

It's very freeing not to pre-read menus before you go to a restaurant or to, you know, I mean, for I'm still there because I want to get my protein in. There's that. But for me, because I'm probably significantly older than anybody sitting here, for me, I'm going to say, and I saw recently a study came out that it's helping slow the aging process. Um I believe it has taken me back 10 years easily. Really? And my the things I'm able to do, the things I'm able, the way I feel in general. I just I feel like the clock sort of reversed itself.

SPEAKER_01 20:30

Well, I've heard that. I've heard longevity, I've heard better, you know, um, just feeling better in your longevity. So because I I always say I don't I don't want to live to be a hundred. I I would like to live to be healthy as long as I possibly can. And then when that with if if I hit a wall, then I'll say, okay, nice, nice knowing you world, and but I I I just want to feel well. So this continues to make me feel well. If it's making you feel well, that's that's the way to do it, right?

SPEAKER_02 21:02

Yes. And I don't know if Dr. Albert's aware that I'm no longer on Eloquis, I'm no longer on dophetatide, I'm no longer on emioderone, I'm no longer on metropolol. None of my heart medications, only the resuvostatin for high cholesterol. And you know what? I let them keep me on it because it's an anti-inflammatory at 20 miles an ounce.

SPEAKER_01 21:26

Okay. Okay, working. So that never hurts, right? Yeah. Yeah. So I'm literally off of all. That's that's really great. Um, I want to ask you because this is um because uh when you it sounds to me like are you getting it covered through Medicare now, through your party for your eye for your heart. No, no.

SPEAKER_02 21:51

Unless you unless you have had this is the this is the caveat they used. Okay. Unless you have a clinically proven Than a previous heart attack or stroke or a cardiac um calcium score of over a certain number, you will not be covered for cardiac conditions at this time. When we got covered the first time, the rules were not clear. And then what the insurance companies did, and you can ask Dr. Albert about this because he is the master of the prior authorization. Um, what they did was they went back to refer to the studies, and the studies were done on people who had a weight condition and a previous heart attack or stroke. So that's so they used the trial studies to say no. So I have many EKGs, God knows, I have AFib, and on many of them it says possible prior to anterior infarct. So what that says, and you can ask Dr. Albert is there could have been we could have had a heart attack, but because we can't clinically prove that I had it, and I think we all know women have much different heart attack symptoms than than than men. It is possible that something had happened at some point when I went into an urgent care or whatever, and by the time I got there it was over. Anything's possible, but but because there's not clinical proof on file, I do not qualify. So under current under the current part plan D insurance plan. So how are you getting your if Dr. Albert's listening, could he please plug his ears? Okay. I have a I learned to stack number one. So in my refrigerator, I do have plenty of prescription, but in order to make that last, I often have to supplement with compound.

SPEAKER_01 24:10

Okay, okay. Um, all right. So so here's here's the main thing. So what we were talking about here is we wanted to discuss like people our age and the issues that we have, and obviously longevity is one. But one of the things when we first started talking about wanting to have this conversation and talking about the bridge program, I originally, long time ago when I first heard about it, I assumed that anyone who needed the medication, this was in the early, you know, when I first heard about it, I was like, oh, this is great, everybody's gonna be able to have it and everybody's able to go on it. And as as things became clearer, I realized that, you know, it's more complicated than that. And so do you because you I thought when when I first heard that you had had heart things, I thought, okay, are you being covered for your heart stuff? But you're not even being covered for your heart stuff. So is it possible? Do you think that you might be able to be covered for did you ever have a BMI that was recorded as high enough without the additional, because that's the one, the high BMI without any other comorbidities. Did you ever have that? And is it on record?

SPEAKER_02 25:24

Could you be on on record? I probably have a BMI of 32, maybe. Oh. Um, not 35. Do I have on record being on this medication and having an A1C of 5.7? Yes, there are a few instances of that. When I had my sleep apnea test, which I believe Dr. Albert even tried to read because it was very unclear, it indicated I had sleep apnea, but technically the score has to be over 50. Well, I was already on the medication when I had the sleep apnea test. So we don't get covered under the new rules. It's a long shot. I know my doctor will try. We're gonna try. Yeah, you know, if they're gonna lend in pre-diabetes, I have the 5.7s on record. And that's being on the medication. I have the 5.7.

SPEAKER_01 26:31

Yeah, and that's also a lower, a much lower BMI for that. So when when Dr. Albert comes on, we'll get all the details. I mean, I've been reading up on this like a crazy person because I just need to know. I have friends, I want everyone to know about it, but I'll I'll defer to the doctor since I am not.

SPEAKER_02 26:49

No, I I mean I'm going to defer to the doctors. I have to hope they're not gonna know how to do this. Okay, and some of us might slip through. I that's my hope, like it did for me the first year before they reverted to the trials, you know.

SPEAKER_01 27:04

I realized, yeah. Um like so many of us are I I don't know about you. I I'm paying out of pocket. I'm going through Lily Direct. And um I I just turned 65 in January. My husband is a bit older than I am, and he's retiring um at the end of the year. Um, and this is gonna make a huge difference in my life to not be paying this amount of money for, you know, an extra it's silly, but an extra 400 bucks a month is gonna make a difference. Like that's gonna be nice. That'll be, you know, an hoa fee or something like that, you know, if I if we move to a smaller place. Um so I'm just curious um how like if if this happens for you, if you're able to get this, somehow or another, you're able to get through with the variety of issues that you've got. Um, how's that going to impact your life?

SPEAKER_02 28:09

Well, it's gonna put a lot of money back in my pocket. I am pretty savvy at shopping for, you know, that thing that Dr. Albert doesn't know about. Um, I'm pretty savvy about it. I learned from the pros who will remain nameless doctor, um, you know, that if I can stay at a lower, lower dose and get a higher dose filled, it's gonna last that much longer. That's why I'm able to have a little stash in my refrigerator right now. Um so I have learned through this community, which I'm not that much in touch with anymore, all the tricks, all the tricks for stocking, for sourcing, you know, lower prices and things like that. Um it would be a big, big impact. Now, I don't know if you're aware, since you're just turning 65, that with any part D plan, if you are on a Part D plan, you have to spend $2,000 a year before everything.

SPEAKER_01 29:17

Not with the bridge program, not with the bridge program. Not with the bridge program, yeah, is a bypass. Luckily, I have an autoimmune disease, and I have like, you know, so uh yeah, eventually it, you know, I do I do um meet that very low deductible 2020, whatever it is, but I do eventually meet it. But um the the the fact that this is a bypass, I know that there are some people who are saying, hey, I'm not gonna be able to, but if but because I'm already getting it through Medicare for my sleep apnea for whatever, but if you're getting it for that, and we'll move to Dr. Albert in a second, but that will that will go towards that. So they may not be getting it for the 50, but it will be going towards, if they're getting it for their sleep apnea, it will be going towards their deductible, which is very important.

SPEAKER_02 30:09

Right. It'll stay with their plan D plan, because my understanding from the research I've done, and I'm sure your research is better than mine, is that you have to be denied first by your insurance, which I have not had an insurance denial on my new plan.

SPEAKER_01 30:24

Well, it's not, it's not, and and this might be a good time to to bring him in, but it's not, it's not your insurance because it's bypassed through a special tea clearinghouse that's doing this. So we'll leave it to we'll leave it to, but I just want to um say like um, let's just you know, we'll talk about why it's um gonna make a difference for a lot of people, but I'm I'm really I really appreciate you talking about your experience because it's it's very different um than what I really originally thought this program was going to be. And and I'm learning, I'm very fortunate. I'm learning that I am a very fortunate person because at one time in my life I did have that BMI that's gonna qualify me. And and not everybody has, and I know um, I really appreciate you telling your story because um people who are coming here want to know, and they really want to know what what will qualify them and what won't. So I'm gonna turn that over to Kat and Ken again. And fantastic Dr. Albert back in.

SPEAKER_04 31:28

Yeah. Okay. Dee Dee, um, I'm curious. Um, I know you mentioned uh, you know, that's why we've been friends a long time, uh, finding the podcast and learning from the podcast. I think that there are probably a lot of people, you know, I would say 60 and plus, that probably have a lot of misconceptions or you know, fears around things like side effects and management of them, what to expect, you know, maybe the kind of care that they'll give. I suspect this will be mostly well, Dr. Albert, like primary care physicians, which I don't always I think we're further along than we were four years ago, but necessarily know about the complexities of this disease and dosing and everything. So I would love to know if you could just kind of give us some insight there, because I think that somebody is watching or listening right now that either is about to go through this and they're trying to understand, right? Or has a loved one, right, that is going to try to, you know, get access or understand if they need or want access. Could you kind of break that down for us a little bit? Sure.

SPEAKER_02 32:28

You have to advocate for yourself, no doubt about it. Um many primary care physicians, Dr. Albert excluded, my primary care doctor excluded, um, don't know everything. In fact, one of my friends lost her insurance coverage. You know this story, Kim. I think I told it to you. And her doctor couldn't get her approved. And I said, This is what you have to write. You had a stroke in 2001. Do you have an x-ray anything? Yes, I do. I said, This is what you write to your doctor, and she did, and she got approved, and she's on it continually now for the past two years through insurance. Okay. So people need to learn as much as they can. Come here to the podcast. Don't just listen to strangers on the internet, except for maybe Deb. Okay, and maybe and Kim and Kat.

SPEAKER_05 33:27

Except for these strangers, you know.

SPEAKER_02 33:30

You know, I mean, there's a lot of misinformation. Yeah. Um I have a friend who is a type one. All his doctors wanted him on it. He can't be approved through insurance. He gets compound. They don't tell him what to do. He comes to me and I tell him you need to up your protein, drink your water, do everything. So you have to advocate for yourself. You have to do your own homework. Um, and reach out to people you know who are on the medication. Don't be afraid to ask us if if, and I don't mean me specifically or anybody, but if you know someone on this medication, go to them and ask them, what do you do? How are you doing your side effects? What are you doing? I mean, for example, a lot of people have heartburn. It turns out some people on certain heart medications can't be taking tomes or whatever. I mean, that's stuff you can ask Dr. Albert, you know, so you can't go on and say, Oh, take some tomes and get a prioleth or whatever. They could have a kidney condition that it's going to affect. Okay. So you have to advocate, you have to ask questions and ask questions of people you know who are successful on these medications. Again, come here to this podcast. There's always people who are guests on this podcast that you can then follow elsewhere, like Dev and Sabrina. I mean, there's a lot of people, the GLP1 winner group, all of that. There's a lot of people that come through this podcast that you can then go follow and go find and do your homework because it's not like you used to do. Yeah. Okay. It's not withholding food from yourself. That's not what this is about. If you don't eat, you won't lose. I mean, it's a total reversal of everything we've ever been taught.

SPEAKER_01 35:28

And I think that is, I don't know if it's unique to you know, Jen Jones, boomers. I don't know if it is. I think it's, I think it's X as well. I I I think, but um, that when we were told it was time to try and reduce, we were told 1200 calories a day.

unknown 35:49

Right.

SPEAKER_01 35:50

No matter who you were. What far and far is that? Like, come on. You you can't live on that. And I have friends now who saw what's happening to me, and they were saying, Well, I'm eating, and just and they're telling me, and I'm saying, what are you how much are you eating? Well, it's 1200 calories.

SPEAKER_02 36:08

I'm like, oh that's the first thing when I know someone who goes on it, the first thing I tell them is T D E calculator. Exactly. T D E dot net calculator, and the number will shock you. Okay, but just deal with it. And then I tell them Kim's rule on the three-byte rule when they claim they can't eat, you know, three bites, three sips, get it going. You know, I learned that from Kim a long time ago, you know. Um, and that's that's what I tell people. Um, but I I think our generation, in answer to your question, Kim, I think there is still a lot of stigma related to this. I think they're still sort of like, well, I know type two diabetics who, you know, changed their diet and did this and did that, and they got off their insulin. Well, yeah, but that doesn't work for everybody. You know, it works for some people.

SPEAKER_01 37:07

Um so we were raised to think that it was, you know, I think even everybody raised to think that it was our fault that we were weak and we were undisciplined, all those sorts of things. Absolutely. We've just been living with it longer. So when you say, Kim, you know, I think it's different for you, I don't think it is different. It's just more time. That's the difference, is that we've been living with it longer. That's the longer because it's the same messaging that we've been getting. You know, you're weak, you're not, you know, you have no discipline, all those kinds of things. And so it's just we've lived with it longer. I think that's a big difference. And so it's harder, it's so ingrained that it's hard to break out. Yeah, definitely.

SPEAKER_04 37:54

Back to the three-byte rule thing with you, Didi, just because I want to make sure that someone knew they understand what you meant. It's not only eat three bites, the whole idea that I tell people when they struggle with food aversion, which is what she's talking about, where you go, I just can't eat. I just can't, yes, you can. That's just a feeling, right? And so what I always do is I take three bites of protein and three sips of water, and my brain reages. Like, oh yeah, we do need to do this. Let's get in our nutrition. And it's just so much easier just to get over that hump. So I just didn't want anybody to think that I was like, eat three bites and then you're done.

SPEAKER_02 38:23

No, you know, it also did sort of I did I because I did it because we've talked about it. And the other thing is is to hydrate. I mean, very often people think they're headachey and they're this and they're that and this, and just simply they're not taking enough liquid in, digging enough water in, and they're going, oh my god, my head, like this, it's not working. And it's like you're not drinking enough. So, and the doctors they should be more educated on all of this by now because I mean, God knows it's it's on Hulu, it's on everywhere, it's everywhere. Okay, you should there should be better access for them. But I'll again, I would just say do your homework, talk to people you know that are on the meds and who have been successful on the meds. Um, and just be careful if you're going out there on the internet because there's a lot of misinformation as well.

SPEAKER_05 39:19

But I want to add really quickly, just just get the three bites, because what I always say now is when in doubt, drink your protein. So if you can't eat the thought of putting any like just chewing, yes, um, drink it. Drink it. And if you don't like the milky stuff, get the juicy stuff.

SPEAKER_02 39:34

But yeah, I'm gonna say I on these meds, and maybe Kim or somebody can relate, I've really not had that problem. I really never have I'm I I'm not that person that looked. I mean, I was the person who got satiety, which I like, yeah, exactly. I want to eat and then I go to eat, and then it's like, okay, well, that's enough, and push it away. Because for me, that's a huge too.

SPEAKER_03 40:03

You're just telling just done. Just yeah, that next one you're doesn't die. Yes, yeah.

SPEAKER_04 40:10

So yeah, it's definitely like I think an ebb and flow too. And I think um, you know, I think what a lot of people, and I find because when you do lives, people come to you. I really try to tell people language that they can have conversations with their doctor as opposed to do this, because I'm just a girl on the internet, you know what I mean? I just I try to say, listen, like this is what you need to ask for. This is what you know, you know, and I think that that's important. So as you go and follow these people, just know, you know, obesity is really complicated. Okay. And it's not your fault. It is biological. There are things that are in your control and there are things that are not, okay. And this is no matter what age you are. It's important to stay in touch with your doctor and have a care team. It really, really is. It may seem because we guys have done diet pills and stuff in the past, like phenomene or fenfen or whatever it is. This is not a set it and forget it situation. You know, you you're on it and you're treating a disease, and so it's a different mindset. Um, and I think, you know, if you're having side effects and things like that, we have tips and stuff, but you should always be telling your doctor about it. I mean, specifically for those reasons that Didi mentioned, you know, issues with kidney, issues with liver, issues with heart, like all of those things are saying that was yeah, yeah. Like with my mom, my mom's 70, right? And she's on them. And um, and and it's just it's important, you know. Don't just don't grin and bear it. Like, don't just be like, oh, this is my last chance, and this is that. You're not supposed to be super sick, and there are ways around. If your doctor knows what they're doing, they can adjust your dose, they can adjust, they can help you manage those side effects about managing them, you know. So I think that's really important, and of course, the protein and stuff, but again, don't eat what protein I tell you. Your doctor knows, right? Your doctor knows because they've done tests and blood work and they know your medical history, right? So when we say things on this podcast with doctors, we're giving ish, right? But your doctor knows your medical history. So those things are are important and don't just like listen to a bunch of trainers telling you stuff either. It's a this is a disease, you know, and um your health's really important. So I just want to make sure you guys have someone you can relate with, some people you could follow. Um, I think we should probably talk a little bit more about the science and why this is important, and then also um uh go into talking about the bridge program and just get some rapid fire QA, guys, so we can cut this and put it out and you guys know exactly what's coming. Does that sound good? Yes, sounds good. Absolutely. So please hang out with us and thank you so much for sharing your journey.

SPEAKER_02 42:33

Okay, thank you.

SPEAKER_04 42:34

Yeah. Hi, Dr. Albert. Welcome in. Hey, thank you for having me.

SPEAKER_05 42:39

We need a pause, we need a pause effect. Well, um, yeah, so sorry about that, Dr. Albert. But yes. Anyway, well, we're glad to have you back.

SPEAKER_04 42:50

We're so glad to have you back. Um, if you could tell us for people who most people like they go back and watch season one and they've seen you on there a couple of times, but tell us a little bit about who you are and how you help people outside of TD.

SPEAKER_00 43:03

Absolutely happy to. Um, so I'm an obc medicine physician by training. Um, currently I'm the chief medical officer and a staff physician at a clinic called Vineyard. That's a national telehealth direct care clinic that helps people manage their weight and kind of broad cardiometabolic health issues. Um, I'm also a I hate using the term, but people use it, an health influencer, however you want to think about that content creator, uh at Michael Albert MD. Um, and that's how a lot of people know me from the content I put out into the world.

SPEAKER_04 43:36

So I love that. Yeah. Dr. Albert um has been with us since the OG days. He was one of the first doctors that was going, hey guys, you want to look at these studies? Let me tell you what's actually going on here. It's a bunch of crap they've been telling you all these years, you know? And so he's um he go back and listen to our first episode of the podcast and our last episode, because we talk about it quite a bit. Um, I will say one of the best things I Ever heard you say, Dr. Albert, is we would take insulin resistance more seriously if we would call type two diabetes what it actually is, which is organ failure. You know? And that was like what I don't feel like anybody says that. And that is a big deal. And this is something to be taken seriously. It really is. So we're so glad to have you. Um, I would really like people to understand a little bit, because we've been talking a lot about Medicare and insurance baloney and all that different stuff. But I think that this is a big deal, what's happening here, right? In terms of having it covered on Medicare for obesity at all. And could you kind of like explain to us why and then maybe where this could go, you know, once and if it is covered?

SPEAKER_00 44:39

Yeah, I think it's important to recognize the sort of you know backdrop that all this is happening on. Like historically, Medicare has treated obesity medicine access differently than treatments for every other chronic disease, right? And so when Part D was passed, Part D being the pharmacy benefit that sets formularies for Medicare beneficiaries, it in and written into the law excluded medicines for weight management, which they really framed as cosmetic for weight loss at the time. And that had to do with a lot of the legacy bias around diet pills and diet eras and uh and the like. And it wasn't until later that you know, CMS, the American Medical Association formally came out and made statements and resolutions to the effect that obesity is a biological chronic health issue, chronic disease, it needs to be afforded the treatment that all other chronic diseases uh are afforded. And and so the issue we ran into is we're dealing with legacy statutes within the the sort of description of benefits for um you know our seniors, and uh and that has to be uh redone, updated, changed for it to meaningfully sort of percolate, you know, in the market. And and the relevance in all of this is that this is the first time since Part D was passed in 2003 that the government has committed to covering obesity medications for the specific intent of helping people manage their weight long term. Um, aside from that, it's only been covered for non-obesity conditions. And so what we're hoping to see is uh over the next few years, the government's running this unique program. They're calling it a national pilot or demonstration. Um, and what's unique about it is it's separate from the core Part D benefit. And this is super important for people to understand. Their $50 a month copay, which will be part of their participation in this program, is carved out from their Part D. It will not go to their out-of-pocket, it will not go towards their deductible. Everyone needs to think about the bridge program as its own entity, it's going through its own railways and it's being judged and evaluated completely separate from Part D and traditional Part D benefits. But if it's successful, when they look at the data, when they look at utilization, health benefits, claims data, and the like, the implications are massive. Because if CMS starts to cover obesity medications long-term for long-term use, for weight management specifically, then typically what happens in the market is that commercial payers, self-funded employer plans will follow suit. So this could be the catalyst for a change in the way that obesity medication coverage and access uh is looked at and uh operationalized moving forward. And so that's the significance. The significance of this is it potentially could be a watershed moment in the way that we cover and allow access and support access uh to these medicines.

SPEAKER_05 47:55

I remember you said that the train has left the station on our first episode. And I would say arguably the train is is getting ready.

SPEAKER_01 48:05

So it's chugging good.

SPEAKER_05 48:06

Yeah.

SPEAKER_01 48:07

Yeah. It's so great because it's it's not only going to, I mean, impact people who are in this, like I'm thinking, and I'm saying this to Didi, it's it's it's wonderful. I'm I'm thrilled that I'm fortunate I think I'm going to be covered, but I'm thinking about the impact it's gonna have on so many other people if this thing, if this thing goes. Like it's just amazing.

SPEAKER_04 48:30

So did that happen with I'm just curious, did that bariatric surgery with Medicare before, Dr. Albert, that you know about? Like, did they cover bariatric surgery?

SPEAKER_00 48:39

It it has had coverage for a while now. I mean, it has pretty strict requirements and things that you have to meet to um be eligible. Um, but there has been legacy coverage for bariatric surgery. There's even been coverage for obesity counseling um through something called intensive behavioral therapy. I would just say like the way that these programs were supported by CMS and the government has been really poor. So even though there has been coverage, I mean, what you're seeing with the bridge is a real commitment, you know, where essentially the government is going to be paying per month like 80% of the cost of the drug, the beneficiary is going to be picking up the other 20%. Um, that's a significant commitment. And and so I think it this is on some level unprecedented in terms of, you know, the the government's commitment to support access.

SPEAKER_04 49:36

Yeah, yeah, absolutely. You know, we've been talking a lot about sort of um the difference here, right, with different generations and um, you know, how telling somebody to eat more protein that maybe has issues, I mean, I think at any age that probably matters. But um, how is it different when you're, you know, 65 plus if you're starting on these medicines um than maybe it is, you know, for someone that's 30?

SPEAKER_00 50:01

Yeah, I mean, just to set the context, there is like no age limit on treating your health, on treating your weights. Um, sometimes this is viewed as something that is really reserved for a certain age group or certain if if there is a real medical indication, regardless of your age, and we're seeing this now too, um, people are getting more comfortable with adolescent treatment and and pediatric OBC treatment. But but on the other end of the spectrum, you know, for our seniors, for the elderly, you absolutely can treat your disease at any stage, any era of your life. And so that's really important sort of context for talking about this. But it does matter because typically the you know, an aging population has there are more concerns around um complications related to medication use. Uh, the therapeutic window is typically narrow, so the margin of error is smaller. So there needs to be more sensitivity to that. Um, there's often more complexity around their baseline health in terms of the other uh comorbid conditions, you know, their functional health and independence, right? All of these things have to be considered. And so it can be on some level a little more complex and require more sensitivity, you know, uh, because the reality is these drugs, they're not getting less effective. If we look at the trend from when they came out, they're only becoming more potent. And as we've seen with some of the recent data that's come out for uh one of the new investigational drugs, retatrutide, there's real rates of complications and side effects in that. And it has a lot to do with the potency of the drug, right? Like you don't get something without getting something, you know? So um I think we just need to be sensitive to that. I'm hopeful that clinics who are utilizing these therapies in their Medicare patients will have the right infrastructure, nursing support, whatever it is that they need to have, um, because these drugs can have side effects and people can have complications and need support. Um, you know, you guys were talking a lot about some of those issues earlier in the podcast, but uh, but it's real and it's and it's even more real for uh, you know, our elderly uh patients, where we really want to be making sure we're in enhancing their health, that they're not uh we're not causing more problems than we're solving for.

unknown 52:30

Yeah. Okay.

SPEAKER_05 52:31

What sort of precautions should our older adults take to preserve their muscle, bone density, overall strength and health while they're on these medications and losing losing weight?

SPEAKER_00 52:41

Yeah, I mean, I would argue it's a non-negotiable, although I'm sure you know reasonable people would disagree. Uh, exercise, like strength training on this to really preserve kind of uh your muscle and your bone integrity and function, right? Um, really getting adequate protein. There's been a lot of revision around the protein guidance for elderly, where they've actually revised it up to a higher minimum requirement now. And I think that's a reflection that an aging body still needs adequate building blocks, right? And what dietary protein is, it's providing that fuel and building block for those functional tissues, right? The muscle and bone and what have you. And so I think from my standpoint, making sure that you're getting appropriate nutrition, enough diversity so you can re meet your nutritional requirements, because the reality is, everyone knows you guys have talked about it all the time on the podcast, you eat less food. And the risk that comes with that is if you're not getting enough nourishment now because you're eating just an absolute lowered amount of food, well, you that's when deficiencies can start. And I've seen them in my patients. Well, we've had vitamin deficiencies and things that we've had to correct. So making sure you're getting adequate nutrition and working with a group that's monitoring it, you're getting adequate physical stimulus, you know, adequate aerobic stimulus, um, you're doing your strength training, you're walking, you're running, whatever your your flavor is. And and then, you know, and and within that, you're getting enough, enough protein. And I think once again, for the Medicare population, that's critically important because their their uh therapeutic range is going to be much more narrow, and and once again, you're gonna have to be even more careful with them. But but it doesn't mean that they can't benefit, right? Like I'm not trying to sound you know raise the alarm like this is such a big problem, but it definitely needs thought. And it's as Kim said earlier, it's not a set forget plant. You know, I've used that phrase a lot to describe how people can benefit from gym. It takes active management, um, but but there's tremendous benefit if if used the right way.

SPEAKER_04 54:47

Yeah. With and I think with a full like care team that knows about it, I think that's good. Totally.

SPEAKER_05 54:52

Yeah. Most definitely. Um, also with with many of our listeners, um, they receive their GLP ones through their PCP or primary care um physicians. Um how can they advocate for the care that they need um when it comes to these these drugs with this new program?

SPEAKER_00 55:11

I I think you guys framed a lot of it really well earlier in the podcast, but but just to kind of restate some of those things, it is important you be your own advocate because there's going to be varying levels of support across different clinic types. Um you should educate yourself on what some of the basic needs are for someone who's taking a medication like this. Um, you should be engaging your provider for support or answers on certain topics. So these are things like what are your goals for treatment beyond weight loss, right? Um, some people can call them non-scale victories. They could be related to improvements in other health conditions. How are you monitoring for side effects? You know, hydration, adequate new nutrient intake, you know, fun physical function. Um what should I do if I feel like I can't eat enough? You know, is there a way to get a hold of you? Should we have a conversation? How should I manage my constipation, nausea, fatigue, reflux symptoms? What do we do if if I plateau? What if my coverage changes? How do we address that? Like these are all questions that you should be familiar with and engage your provider and your clinical team around. Um, sometimes it's even important to say, like, are you even comfortable having this conversation or being able to manage this? Or should I be seeking out a specialist, like an obesity medicine clinician? Um, typically I've found primary care doctors uh some are more comfortable than others and are willing to kind of at least say, hey, yeah, I'm waving the white flag. I'm I'm probably not the best person for that, but I'm more than willing to support you and encourage you to go work with you know a specialist or someone else. And um, the last thing I would say is just like have your documentation, right? Like know your prior weight history, what was your highest weight you ever achieved? Is this particularly important for the bridge uh qualifications, your medication history, your comorbidities, your lab results, you know, your pharmacy information, all of this is gonna need to be reported and handed over to your medical team. They're gonna need to document it as part of a bundle for the authorization that they're gonna submit to the central processor who CMS is using. So um this needs to be captured in the documentation. It's critical, I can't I can't state that enough. If your highest previous weight and highest previous BMI are not captured, if your weight loss history is not captured, if the medications you've been taking during any prior trials aren't captured, um if your health status isn't captured in terms of what chronic health issues you have, even if they're well controlled, that still needs to be captured. This is all things that people need to be writing down and bringing to their doctor, or at least discussing so their doctor can capture that information and submit it during the authorization process.

SPEAKER_05 58:00

I'd imagine that's probably a good um a good practice to probably start working looking for that now.

SPEAKER_00 58:06

Yes, start now. There's never too early to start digging out your sleep reports, like Dee Dee said, finding your your lab test that an A1C that puts you in the pre-diabetes range, like all that stuff. Like start it now while you have time. Program goes live July 1st, you know, so it's gonna be here right around the corner.

SPEAKER_05 58:26

I have another question. And I know Dee Dee said we we have to be delicate about this this topic with Dr. Albert. Um, so some of us are on GLPs now, let's say, and they um are interested in the bridge program. Um would compounding or let's say a telehealth that has uh provided um a way to get that um the the compounding is that counted as your medical records as well for the bridge program?

SPEAKER_00 58:56

Yeah, I would I mean you get credit for it for sure. It's part of your medical history. You know, compound that medicine is a medication, you know. So it is it is part of your story. Now, does that mean you could stay on a compound at the bridge price and and the government pay for that? They're only paying for FDA approved products that were part of the negotiated. So that would not translate, but your history absolutely translates your history tells you. Yeah. Okay.

SPEAKER_04 59:20

That's good. That's good. Okay, I think let's do some rapid fire um Medicare Bridge program questions. That way I can chop this up and put it all over the internet and help people. How's that sound? Um, I think we talked about a little bit in the top half, but if we can just summarize real quick, what is the Medicare Bridge program?

SPEAKER_00 59:38

It's a short-term CMS demonstration that provides eligible Medicare Party beneficiaries with access to certain GLP1 medications to help them manage their weight and maintain that. And that's really important because CMS uses that language specifically, which is a big deal, maintain weight as well. The program starts July 1st, 2026, and it runs through December 31st of 2027. To be eligible, to be considered, you must be enrolled in a part D program. All right. If you're in another program that's not part D, then you are not eligible. And this doesn't, age is not a restriction. There are some people because of disability, because of particular medical conditions that have Medicare benefits and are younger than 65. This is it's age agnostic. It has to do with enrollment status in Part D.

SPEAKER_04 1:00:33

Okay. So who will qualify for GLP1s in the Medic Medicare Bridge program?

SPEAKER_00 1:00:40

So typically it's framed as people that have a certain BMI level, and the lowest level that qualifies is 27 with certain uh comorbidities like pre-diabetes, chronic kidney disease, or a BMI greater than 30. Um, if you have a BMI that has separate coverage indication through Part D, I'm not BMI, condition with separate coverage, uh, like diabetes, like uh prior history of heart attack, stroke, or peripheral arterial disease, uh like obstructive sleep apnea of moderate severity, uh then you are not allowed to use the bridge program. So at least not for the specific medication that that has that Part D coverage. Uh they're really trying to make that distinction. So, really the bridge program is for people that have a qualified, qualifying BMI, have a comorbidity that CMS recognizes, that doesn't have a traditional coverage policy around, those are the people really that they're trying to steer uh bridge uh to. And and so um there they're they are drawing that distinction. This doesn't overlap with traditional Part D coverage. If you have you can qualify for treatment through Part D, then they're gonna steer you towards that and you won't be eligible for um for for this new program.

SPEAKER_01 1:02:04

Um, Dr. Albert, the you were mentioning the 27 and then you said 30, and there were additional comorbidities with comorbidities with 30, but there's also 35 and above with no additional comorbidities. That's correct, right?

SPEAKER_00 1:02:20

Yeah, I mean there, so the to get the specifics, there's a lot of different ways you can qualify. Definitely go through the whole rundown, right? You know, because it depends on your threshold. I think the basic way that people can think about it is, you know, did you at least have a BMI of 27? There are nuances around the qualifying uh comorbidity status. Um, but just as a general rule, I think that's a place to start for people to think about and have a conversation around. Their doctor, their clinician, whoever they're working with, is gonna have to help them figure out if they also have a qualifying comorbidity for their BMI history. Um, but I think it's probably the easiest for people to think about well, if I at least have a BMI of 27, there's probably a conversation that's worthwhile to have around this.

unknown 1:03:10

Okay.

SPEAKER_04 1:03:11

Um, and then I know we talked about documentation, but let's just say, let's put it here so we have it. So documentation that you may need to qualify or that you want to get together would be lab work, you know, several things you mentioned, were there?

SPEAKER_00 1:03:25

Yeah. Baseline weight, baseline BMI, date of therapy initial uh initiation, like if you've been on GLP one in the past, you know, what what obviously what is your current weight? Do you have any obesity-related comorbidities, you know, your medication history, any other prior, you know, weight loss efforts. Um, you know, that getting all that information along with the labs, as you stated, is going to be important to put together as part of a documentation package for the authorization. And so what you can do is you can, you know, do some work to find that information and then either share it directly with uh the clinic or provide it verbally during your you know assessment visit. And and then they can obviously document it and and you know put that information together as part of the submission process.

SPEAKER_04 1:04:17

Okay. So if you think you qualify for some of these things we've talked about, the first step step for you to take would be to gather this and then make an appointment with your doctor. Does that sound right?

SPEAKER_00 1:04:27

I think that's right. Yeah.

SPEAKER_04 1:04:29

Okay. Um, what are some common hurdles that patients might face when they're seeking coverage through the program?

SPEAKER_00 1:04:36

I the one we've already highlighted is, you know, the distinction between qualifying for bridge versus one of the standard Part D coverage qualifications, right? Um, so if you were someone, uh that your doctor's gonna need to help you figure out, but it really has to do with do you meet criteria that is currently approved for one of the specific agents that Part D does cover? So it would be a non-weight related uh condition. Um other issues that you know people are gonna run in is just not having this information documented. So like it needs to be documented in the note that's submitted with the authorization. So you might have to advocate to your doctor or nurse practitioner, whoever is seeing you, to make sure they're capturing that and they're submitting it along. Um, you know, if you have fractured documentation, that's what always gets automatic denials, requests for additional follow-up. It's gonna delay approval, slow everything down. Um I think recognizing that it's a fixed cost, right? And the the cost doesn't go towards your out-of-pocket or your deductible, right? So you're paying $50 a month. There's not an additional responsibility on top of that. It's it's a flat $50, and the government's picking up the rest. Um and I think just you know, with everything, just making sure that the pharmacies process this correctly. One of the things I'm concerned about. Concerned about is the implementation of this. There's been a lack of clarity. It's been a little bit confusing on what the right sequence is in order for people to qualify. I'm not going to try to confuse people too much, but it may be true that before you can get a prior authorization processed, that your doctor or your nurse practitioner or whoever has to send a prescription to the pharmacy that's going to be filling it. And a claim needs to be generated and actually rejected initially. And that's what CMS has said. That's been a little bit odd. My understanding and my read on that is the reason that you need a pharmacy claim that is initially created and denied or rejected is because it creates a it creates that history around it that the CMS is then using to monitor uh you know the bridge qualification. So it's like just like creating a ticket. You know, you become your the system is now aware of you. Um and then on the back side of that, after the claim gets rejected, the prior authorization can be submitted. Um uh and I I think it has to do with the funky way how they're they're taking this off the railways of Part D, and it's in its own separate category and has to be processed uniquely. Um, so I'm sure we'll get clarity, as with all things, there's especially with the government, there's very you know implementation. So I think we're all gonna still be learning, but that might you know trip some people up because maybe they're not used to sending a prescription first before the prior authorization. And so that may be something you have to educate your doctor about that hey, uh, you might, in order to kick this thing off, you might have to send an initial prescription, that prescription get denied at the pharmacy, and then the prior authors submitted on the backside of that. So that's the those are some of the the hurdles I'm I'm worried about for people. But hopefully, you know, we'll get more clarity on that in the coming weeks as it's implemented.

SPEAKER_04 1:08:00

I think that's really good because I agree. Like it's think about how many people get rejected for these treatments ever, and then they think, oh, like I'm done. Like they didn't even bother appealing, right? Or exhausting their appeals. And we should always tip, hear me out. Always exhaust your appeals. Okay. Like you have rights, okay? Um, I know we covered this a little bit, but um, are there there any special eligibility or documentation considerations for patients who have previously paid cash for treatment, um, use telehealth services, or received compounded medications? I think the answer was that's all part of your medical history, right?

SPEAKER_00 1:08:34

Yeah, I mean, it doesn't preclude you from qualifying for bridge, you can meet the standard criteria. Um, and it's certainly uh a credit to your history, you know. So if you were someone that's done compounded, you know, I don't you've done whatever and you've lost a bunch of weight, like you still get credit for that. So you should still be using your starting weight and BMI as your reference weight uh during the submission, you know. So that that's probably an area where some clinics are gonna get tripped up. They're gonna use the current weight in BMI and it's not gonna qualify you, especially if you're someone like Cat who's lost a lot of weight in the past. If it's not represented your history the right way and documented as such, then you're not gonna get credit for it.

SPEAKER_05 1:09:19

Yeah.

unknown 1:09:20

Yeah.

SPEAKER_05 1:09:20

Uh for listeners who didn't or don't qualify for the Medicare Bridge program, um, what options are available to them today? And what steps would you encourage them to um take next?

SPEAKER_00 1:09:32

Yeah, so there are a few options. Um, one would be do you cover for another can or you do you have any coverage for another indication, like type 2 diabetes, like some of the cardiovascular pathways? Uh we have a new uh indication for Wagovi, which is uh stage two, stage three fibrotic liver disease, also called MASH. Um sleep apnea is one that's gotten a lot of attention with Z-Bounds uh for a expanded Z-Bound indication. So can you be covered for something else? Once again, uh many of those are covered under commercial plans uh for those kind of other indications. Um there are uh a number of cash pay options now where uh pharmacies, even pharmacies affiliated with the manufacturers, offer like direct pay uh and have transparent pricing on many of the FDA-approved GLP1s. There are non-GLP1 therapies that are currently generic medicines or have branded alternatives that you can pay cash for right now if if you don't qualify. So there are a range of medication therapy options now that expand beyond, you know, just needing to have insurance coverage.

SPEAKER_04 1:10:45

Yeah. And I think like um things to consider, like that, you know, I've I've we've talked about before things like contrave and qsemia, like these older anti-obesity medications. And um, I think uh what also is important, guys, is four years ago and we were going through this, this medicine was 1400 bucks a month, you know, and now it's you know 350 to 500. So even though that's quite outrageous, we've come a long way in a short amount of time, right? And the fact that it's you have these options available that our brand, like, you know, everybody knows I just want you to get safe medicine, right? And now we have good care, right? But there are a lot of options, like there are, and I don't think people know about them. I mean, I think one of the other ones to mention is there's a generic um, I don't know how much it costs now, lyri glutide. That was the first one I was on, yeah, you know, um, and so that's a daily one, but I experienced no food noise on it. I lost weight on that. I I experienced inflammation reduction on that. So I think that one gets kicked out of bed a lot. Um, but honestly, sometimes it's just me, right? What is best for you. And now the Wagovi pill that has come out, right? Um, even it's I want to say like 150 a month to get started, and it yeah, I mean it's like it's I don't know what it depends on when you're watching this, but regardless, none of these are, you know, ideal prices, right? But it's way better than $1,400 a month. So I don't want people to freak out and still think because they haven't really been, you know, in the land of TikTok with us, right? That these are still $1,400 a month and that's your only option. There are options, there are good options. Okay. So it's focus on focus on getting good care first. That'll all fall into place, I promise. Okay. Um, I think uh we had one last question. Let's see. Um, all right. So for I think we may run into this. Um, for Medicare beneficiary listening today who has spent years struggling with weight and may blame themselves. Um, what would you want them to know about weight?

SPEAKER_00 1:12:39

I mean, what I would want them to know is that obesity is not a character flaw. It is not a failure of willpower. It is a chronic, biologically mediated disease that is heavily influenced by genetics, your physiology, the medications you take, the environment you live in, your sleep, your age, your hormones, your mobility, a range of factors. And many people have been told their whole lives to try harder when what they actually needed was just evidence-based treatment. And so, you know, I I think now what we're seeing is the turning of the tide in terms of society recognizing this as something that deserves treatment. And it's not something that's, oh yay, like you guys get the privilege of of of you know having access to this. It's like you always deserve this, right? So I think it's we're we're seeing that change. It's never as fast as we want, um, but it feels inevitable. You know, we're seeing it brick by brick being being uh laid down. So it does give me a lot of hope. Uh, even to to go back to the train metaphor, I I think it it does have a feeling of inevitability around it. And uh certainly I I want it to have happened yesterday. Um but I think bridge is a representation of this continued progress, and and for that I'm I'm I'm hopeful and grateful.

SPEAKER_04 1:14:08

Yeah, yeah. I'm hopeful and grateful too. Um we've come a long way in a short amount of time. And when it comes to medicines for things like this, it's just not the case. So we've had a lot of, a lot of, a lot of progress. Yeah. Um, I love that too. The only thing I would say, like, and we can go around the horn if there's anything you want to say, but um, is that when it comes to strength training, it is, I think it's very common for people to think that you need to like go in the gym and be like heavy lifting because you would be so surprised, like of just using your body as resistance and using resistance bands and kettlebells at home. You know what I mean? There's there's also friends like get on the internet, get on YouTube. You cat and I do exercises on here. Um, we have little workout sessions where we do things and stretch, especially if you have mobility issues. Don't think that you just gotta go diet culture the shit out of it and pop into a gym at 65 plus years old. And then if you can't do that, that means you can't do strength training. Not true. Lots of things. Go and do the go to Google, search different things. You'll see videos and all this stuff for free to help you with that. Okay. Um, not just here anywhere.

SPEAKER_05 1:15:10

So that's one thing really important. Really important. Countless, countless amounts of um, I would say, um tutorials and how-tos, people who are new or who are injured or who are um are that can't move out of their chair. There's there's there's a a plethora of videos and how-tos out there.

SPEAKER_04 1:15:33

Deb, what about you and um Didi? Did you guys have any like common misconceptions when you were getting started that like you would want people to know about as our closing thoughts? That are like bullshit. Leading the witness, I know.

SPEAKER_02 1:15:51

I guess for me it was that you the diet culture piece was still there, that you were just gonna stay on a diet, but now you were gonna have help with a medication. And it's not that. Um, it's the food noise. I mean, I remember going to the refrigerator and wondering what was wrong with me the day the food noise shut off. Um it is something that until you experience that you don't you can't wrap your head around it, pardon the pun. Um but it just falls into place and then it makes it easier. But I I did want to mention one thing, um, and Dr. Albert could ring in on it, is um when we're talking about older people need to be have the movement and do the strength training and all of that, when we lose muscle over 65, it is very difficult, if I'm not mistaken, to regain muscle as you get older. And I think for many people who suffer from obesity and are aging at the same time, it's a bad combination. Um, they probably think they can't move because they haven't in so long. And so, like Kat said, start with a chair exercise or something. But once you lose the muscle, it's very difficult to gain it back.

SPEAKER_04 1:17:18

You can do it, but you gotta work at start early. Yeah, don't wait and be like, you know, like start now. Seriously, start now. Start before you even get approved. Start in your chair, resistance bands, you know. Yes. Anything, any final thoughts?

SPEAKER_01 1:17:33

Well, similar. Um, I think um, you know, the the thing that I I had gotten enough of a reality check about the fact that I knew that that culture was BS. Like I recognized that I still struggled, but I knew it was BS at what I'm hearing from so many friends um who are of my age and older, and then some who are younger who are coming up, just in any age, really. I don't even think it's exclusive to our age, is that sense of the that it must be restriction, that it's the the language of calorie deficit is very different than restriction. Yeah. And I think to look at the TDE calculator was incredibly, as Dee Dee and I were saying, to look at the TDE calculator and see what the requirements are for maintaining your weight and then cut back anywhere from 500 to even. I had one friend who was, you know, I said, you don't even have to cut back 500, you could cut back 200, it'd take longer for it to go off. But you know, don't suffer, don't suffer. We that's the thing that for so many years we suffered and we restricted. And um if if if these I know that there's a there's a percentage of the population right now that do not have success with these medications. And so that breaks my heart. But those of us who are lucky enough to have some success with these medications, I say don't once once you're being supported, once you have that sort of base underneath you and the food noise goes away and you get some satiety, don't suffer. There's no need to suffer with this. It's it'll take what it takes to to drop whatever it is that you've accumulated over the years, but it took you a long time to get there. It'll it'll it'll come off. It'll come off if you're one of the lucky ones who it's working for. Don't suffer. There's no reason to suffer.

SPEAKER_05 1:19:43

There's no glory in pain. There is no glory in pain, Kat Carter. That is for that's messed as my older sister's quote, but yes, that is no glory in pain. Yeah.

SPEAKER_04 1:19:57

I think for me too, like I want everybody to understand that something I've learned from Dr. Auber like since the beginning, right? And he makes great content. Go watch it. Like your weight's regulated here. Like there's it's a regulation center. You have like a it's like a thermostat, right? And so it's trying to always pull you back to this what he calls the set weight or what do they call the set weight, right? Which is probably the biggest weight you've ever been, right? And that's not up to you. That's just not up to you. And you can restrict and you can exercise and all the things, but the chances that it's gonna come back are high. And that's one of the probably biggest reasons you are where you're at. Okay. So you have to, you know, get the help that you need. And I think also, too, like Deb mentioning that there are people that maybe this doesn't work for, just because one does not work for you does not mean another one won't. These are synthetic versions of these hormones, okay? So just don't like if you you may be like, oh, this one makes me too sick, right? Or oh, this one I didn't lose any weight on. I was on it six months. Just because one doesn't, does it because I mean, like one of them's GLP one, another one's GIP, like there's and with GIP. So like it just they affect people differently. So don't just be like, ah, one didn't work, I'm done. Talk with your doctor, stay in connection with your providers and your care team, right? And and any other specialists that you may have, like keep them all in a loop. It's a lot to take on, but it matters and you matter, and you're worthy of care and worthy of treatment, and you shouldn't have to like slink off and be doing this stuff on your own. Okay. So, you know, that's what we fight for. Um, anybody got anything else?

SPEAKER_03 1:21:24

I think there's anything wrong.

SPEAKER_04 1:21:27

I have to gut check with my doctor friends. I'm like, that screw that up. Was that right? I'm trying to oversimplify things, you know. Um, what do you think? Good episode? Like we did.

SPEAKER_05 1:21:38

Great job.

SPEAKER_04 1:21:39

We did, all right. Um, can you tell us um where people can find you, like with your socials, if people want to see you possibly um and as a doctor, where they can go?

SPEAKER_00 1:21:52

Yeah, I'm at Michael Albert MD uh on all my socials, and I'm on most platforms. And I practice at Vineyard. Um, so you could go to joinvineyard.com if you want to be a patient of ours. We've got a great team there, and uh, we'd be happy, happy to care for you. Awesome.

SPEAKER_04 1:22:11

All right, everybody. This was wonderful. Good show. Thank you for this lovely conversation. Friends, please feel free to reach out if you have any questions. We'll do our best to get you with doctors that that on the show that we trust. Okay. Uh, and that's a wrap. We'll see you next week. Asta La Pasta.

SPEAKER_05 1:22:29

Asta La Pasta.