119: Can Medicare Finally Cover Weight Loss Meds? Understanding the New GLP-1 Bridge Program

We break down Medicare’s brand-new GLP-1 Bridge Program and explain why headlines are both true and incomplete. We lay out the real eligibility rules, the $50 copay promise, and the smarter questions to ask so you and your clinician can find the right coverage pathway. 

• why Medicare historically excludes weight loss medications and what changed with modern obesity medicine 
• what the GLP-1 Bridge Program is designed to do and why it is not universal coverage 
• the $50 copay detail and why office visits labs and deductibles can still affect total cost 
• who does not qualify because another Medicare Part D pathway may already apply 
• the three eligibility “doors” based on BMI and specific risk conditions 
• which GLP-1 medications are included at the time of recording and the planned program timeline 
• how to prepare for an appointment and the exact phrasing that helps your clinician pick the right route 
• why checking CMS and staying current matters as rules evolve 

You can send us an email, you can find us on Threads, follow us on Instagram, or leave us some fan mail.

Transcript

Welcome And Bridge Program Overview

SPEAKER_00 0:00

Hi, welcome to your checkup. We are the Patient Education Podcast, where we bring conversations from the doctor's office to your ears. On this podcast, we try to bring medicine closer to its patients. I'm Ed Delesky, a family medicine doctor in the Philadelphia area.

SPEAKER_01 0:15

And I'm Nicole Rufo. I'm a nurse.

SPEAKER_00 0:17

And we are so excited you were able to join us here again today. So what are we going to talk about today, Nick?

SPEAKER_01 0:24

Today we have a very exciting episode about Medicare's new GLP1 bridge program.

SPEAKER_00 0:33

So you know, I had a few weeks ago, a patient asked me a question I have been hearing more and more often. They say, I've heard that Medicare finally covers Wagovi now. Can you prescribe it for me? And it's a great question. And it's become one that's become much more complicated over the last few months. You may have seen headlines saying that Medicare is finally covering weight loss medications. And while those headlines aren't entirely wrong, they also don't tell the whole story, which is what we're going to try to do today. So today we're going to talk about Medicare's new GLP1 bridge program, what it is, who it's designed to help, who it doesn't apply to, and how you can have a more informed conversation with your healthcare clinician. So before we get started, one quick note the Medicare GLP1 bridge program is new, like brand spanking new. Like this is coming out, this episode is coming out two days before the program launches. And like many new healthcare programs, details may continue to evolve over time. We are discussing the eligibility, excuse me, we are discussing the eligibility criteria available at the time of this recording. But if you're interested in the program, be sure to talk to your doctor, nurse, PA, whatever, about the most up-to-date information. All right. So

Why Medicare Created A GLP-1 Bridge

SPEAKER_00 1:51

let's start with why this program even exists. For many years, Medicare generally did not cover medications prescribed solely for weight loss. That policy dates back decades, long way before today's GLP1s. Wait, long way. That policy backdates decades, long before we had today's GLP1 medications and before we understood obesity the way we do now. Today, obesity is recognized as a chronic disease. We know it increases the risk of heart disease, diabetes, stroke, kidney disease, sleep apnea, arthritis, and many cancers. At the same time, medications like Wagovi and Zeppound have shown that they can help many people lose significant amounts of weight and regulate appetite dysregulation while improving important health outcomes. The challenge has been access. The Medicare GLP1 bridge program was created to expand access for some Medicare beneficiaries while broader Medicare coverage policies continue to evolve. So generally, this is not Medicare saying everyone gets a GLP one. It is, as the name suggests, it is a bridge. So

Copays Deductibles And Hidden Costs

SPEAKER_00 3:09

one of the biggest questions people probably have is if I qualify, how much will this cost? And I think many people will be very pleasantly surprised. According to CMS, eligible medications furnished through the bridge program have a $50 copay for qualified Medicare beneficiaries. That is a significant difference compared with what many patients have been paying out of pocket or for cash-only prices, or frankly, not being able to access them at all. It's also worth remembering that the copay applies to the medication through the bridge program itself. You may still have costs associated with office visits, lab work, or other parts of medical coverage, depending on your coverage. This also does not, to my understanding, contribute to your deductible on your Medicare Part D or advantage plan programs. So you will still have to meet that deductible if you are going to use the bridge program. This is just a continuous recurring cost that does not contribute to that. So

Who Is Excluded And Why

SPEAKER_00 4:18

we can before we start talking about who qualifies, I felt like it was best to talk about who does not qualify currently because I don't want anyone getting excited walking into this episode to say, oh my gosh, this sounds great. And then at the end of it, find out like it wasn't for me. So if you remember one thing from today's episode, remember that not qualifying for the bridge program does not automatically mean Medicare won't cover your medication. It often means there is another pathway that already exists, and that is the reason they're not covering it through the bridge program. So if you have type 2 diabetes, moderate to severe obstructive sleep apnea, or a liver condition called MASH, those conditions are already eligible for many Medicare Part D coverage under certain circumstances. That means you generally should not receive your medication through the bridge program. Instead, you should work with your doctor through getting your benefit of the medication through your setup Medicare Part D plan or advantage plan. So being excluded from the bridge program is not inherently bad news. It means that it wasn't, it's not for you. If you have one of those three things, you have another reasonable way to get a GLP1 medication. Did that make sense?

SPEAKER_01 5:45

Yeah.

SPEAKER_00 5:46

Any thoughts? Okay. I feel like this is this piece is going to become very frustrating for people because I think the way of the patterns I've been seeing are that up front, the Medicare covered for the medications does not appear to be good because many people have to reach their deductible first. And then once they get the deductible, which up front may mean that the medication is $500, $700, $1,000. But many people for in the Medicare bucket, if they're using one of these conditions, type 2 diabetes, moderate to severe obstructive sleep apnea, and mash, once they get the deductible, there is better coverage. It's getting to the deductible. And I think that's a dang deductible. Yeah. I think people get a sticker shock initially when they go to the pharmacy and the pharmacist is like, please give me $700. And no one was ready for that. I don't blame anyone. So then people will be like, oh gosh, I wish I would just like qualify through the bridge program. So I see this as a pitfall happening early on.

SPEAKER_01 6:52

So who does actually qualify for this?

Eligibility Rules And Three Doors

SPEAKER_00 6:56

So eligibility, first and foremost, is for people who are 18 years and older and have Medicare. Medicare with a Part D, which is the prescription part of Medicare, or an advantage plan. You have to have those three, a couple of those three things. In the documentation, they will want to recognize that you are actively participating in ongoing lifestyle changes. And literally, who isn't? So I'm not sure why this has to be written down because who isn't always trying? And that you're receiving the medication for weight management. The first, if you qualify for all of those things, the first and easiest pathway, if you aren't excluded from the program, like we talked about before, is that you have a BMI of 35 or higher, a body mass index. This is a measurement of your body mass as a measurement of your weight and against your height. If it's 35 or higher, that is the simplest pathway to get access to the program. The second door is all of the stuff I said before, but the BMI changes. So if the BMI is 30 or higher, and you have one of these three conditions, meaning heart failure with preserved ejection fraction, chronic kidney disease, stage 3A or lower, meaning 3A, 3B, 4, or 5, or uncontrolled hypertension, despite taking two blood pressure medications, you would qualify for the bridge program. Or door number 3, which is a very large group, a BMI of 27 or higher, and pre-diabetes, a previous heart attack, a previous stroke, or something called peripheral artery disease that gives you symptoms. This is decreased blood flow to the legs because of plaque and calcification that gives people pain. If you have a BMI of 27 or those things, you also qualify for the bridge program right now, at this moment of recording. So these seem like really specific concerns because these are the conditions where obesity can have a particularly large impact on one's health and where weight loss may meaningfully reduce further risk. These aren't random diagnoses. They reflect the populations that Medicare chose to prioritize for this program. Of course, this does not mean that someone outside of these groups would not benefit from treatment. It just means that this particular insurance program has narrower eligibility than the FDA-approved medical indications for these medications. We need to clear that up too. Like if you don't, just because you don't qualify for one of these does not mean it is not on the menu for you. I think getting access for this specific group of people has been ignored for a long time. And I don't see a lot of other private insurance companies doing it this way. So I am excited that this can get people who need these medications access. I think

Covered GLP-1 Meds And Timeline

SPEAKER_00 10:14

it also may be worthwhile to explain which GLP1 medications are going to be covered. So they will be covering right now, at the time of this recording, the Zepbound quick pen, which I'm not sure if we spent a ton of time talking about this, but it is a flexible dosing. It's actually not flexible dosing based off of the um how they tell you to use it, but it is a multi-use pen that you draw up the amount of medicine that you're going to use and can reuse that pen with a different needle. So I like it because it's less waste. It's not like one point and shoot needle, and like that just goes in the trash and garbage and goodbye. Thanks, environment. Like I like the fact that like it's a one, it's like a for-use pen officially. So that's nice. Um, there's also both Wagovies, injectable Wagovy and oral Wagovy. And so will Foundo, which is Eli Lilly's medication. It's the oral one that can be dosed at any time. Another stipulation about this is that this is a is technically a temporary program. So it goes live July 1st, 2026. And as of right now, all of the marketing is that it is set to expire at the end of December, 2027. My hope is that they will come up with a different program thereafter. I've heard whispers of them naming a different program balance, but we're going to see if this bankrupts the country.

SPEAKER_01 11:52

So can't do any more damage.

SPEAKER_00 11:54

Yeah, I mean, as if there were another one.

SPEAKER_01 11:56

Let people have their GLP ones.

SPEAKER_00 11:58

Honestly, yeah. I really at this point, I think I don't understand the economics of it completely. I think it's on the companies that make them at this point to lower the prices if I was to pick someone who had to make a move. All right. So we

How To Prep For Your Appointment

SPEAKER_00 12:12

can talk about a little bit about preparing for your appointment. So if someone thinks they may qualify, we think a little preparation can go a long way. Um, think about your medical history. Have you been told you have prediabetes? Have you had a heart attack, a stroke, kidney disease, or heart failure? Make sure you bring an updated medication list. Think about if you have a history of thyroid cancer. Instead of asking, can I get Wagovi? Try saying, would I qualify for the Medicare GLP1 Bridge program? Or would this medication be covered through my Medicare Part D plan? That question helps your whoever's taking care of you identify the right coverage pathway from the start.

Key Takeaways And Where To Verify

SPEAKER_00 12:50

So the biggest takeaway today is the Medicare GLP One Bridge program represents progress. For years, many Medicare beneficiaries had little or no access to anti-obesity medications. And today, there's another pathway for some patients. It won't apply to everyone and it doesn't eliminate every insurance hurdle, but it reflects something that we've learned over the last decade. Obesity is a chronic disease, and evidence-based treatment matters. If you've ever been told that in the past that Medicare wouldn't cover medication for your weight management, it may be worth revisiting that conversation with your healthcare clinician. The answer still may be no, but for some people, the answer may finally become yes. So we think it's important to stay informed. We think that medicine changes, research changes, insurance programs change. A conversation you had a few years ago may be very different today. So one of the best things you can do is stay informed and keep asking questions. And that's what we're all about here. So because this program is new, I'd like to end the episode with a brief note that we are encouraging listeners to check the CMS website or speak with their own doctor or nurse for the latest eligibility criteria. We hope that this keeps this useful, but also helps this be a continuing living document that encourages future growth and development because this program will likely change, even though it is just new. And

Banter On Portland And Travel

SPEAKER_00 14:16

now for the banter. Technically, it's been two weeks since we've had banter, banterized, and we've recorded because we did a little like pre-recorded episode. Um I guess I'm gonna since we have like a national worldwide, it's it's a worldwide audience. It is true.

SPEAKER_01 14:33

It is true.

SPEAKER_00 14:34

I won't say any disparaging things about Portland, Oregon, but I had a good time there with my friend for his bachelor party, and that's all I'll say about that. But just you know, if you're going to Portland, maybe don't think twice. That's all I'll say. Thanks, Portland. Um, moving on to better bigger and better things. Uh, what should we talk about?

SPEAKER_01 15:00

Well,

Love Island Movie Night Explained

SPEAKER_01 15:01

we have Love Island, of course.

SPEAKER_00 15:04

Of course.

SPEAKER_01 15:05

I think we have a proper movie night in our future.

SPEAKER_00 15:09

Why don't you go ahead? Because we have a lot of um, you know, like people in their 40s and up listening to us. Um can you tell us a little bit about why movie night is important in Love Island Lore?

SPEAKER_01 15:24

Yeah, movie night is the best night of our summer. We did not get it last summer. And so on Love Island, which is the best but also worst reality TV show to ever grace our screens, there is um all the islanders, like the main cast is in the villa. Boys and girls, they're all trying to find love, you know. And then a couple weeks in, the boys secretly go to like another villa called Casa Amor, where there are new girls, and then their original relationships get put to the test. To the test, and then like they decide if they want to come back with a new girl to the villa or if they want to go back to their original connection, but then so then they do that, they come back, and then there is movie night, where all of the original villa people, the islanders, plus or minus the Casa Moore people that come back, all sit down and they have this big giant TV screen in front of them, and they all watch what each other did during Casa Moore, and it's just really great.

SPEAKER_00 16:37

It does brew for great, great entertainment, great drama, and great drama. They did a little bit of that when the boys initially this were the boys leave to go to Casa Amore, and they live streamed their initial interactions with the uh the new girls, the new girls, and let me tell you, it felt like it should have been a premium subscription for what we watched on our screen. We do we pay for the premium subscription because we get to watch these things, but um not that kind of premium subscription. No, not that kind of just for peacock. We just pay for peacock, like some people we know draw the line. They draw the line at Peacock. We're like, oh, do you watch these shows? Do you watch do you watch Bravo? Do you watch Love Island? And they say no. I don't know if Peacock, period.

SPEAKER_01 17:27

Hmm.

SPEAKER_00 17:28

Hmm. Anyway, um, what else did we uh speaking of this event? We

Graduation Party Food And Friendship

SPEAKER_00 17:34

uh congratulations to Pri. Um she graduated from dental school and all of her your wrist is ailing you over there, huh? You really didn't bump it on anything that we can remember. Well, she graduated from dental school and we got to celebrate her graduation party yesterday at Karthik's parents' house, which is beautiful.

SPEAKER_01 17:56

Oh my god, I'm obsessed with Karthik's mom. She's great, she's so great. She's like, Pre needs to marry Karthik simply to have Pooja as her mother-in-law. Like, what a gold mine that woman is, truly.

SPEAKER_00 18:11

Of like, obviously, of like because she's like so wonderful. She is so wonderful, yes. Um she was so discerning when I was saying goodbye. The funniest thing, like, of course, she was always like, she thinks well of me, and I'm very grateful for that. But then as we're leaving, I'm like, oh my gosh, it was so great to see you. I missed you so much. And I'm hugging her, and she's like, Wait, how long has it been since you've seen me? How can you possibly miss me if it's been that many years? And I was like, wow, this woman does not pull punches, and this is why Karthik is the way he is to some extent. But oh my goodness. I was like, wow, that was great. And I was like, you're I'm allowed to miss you for a long time and not see you.

SPEAKER_01 18:55

That's so funny.

SPEAKER_00 18:56

Your poor wrist over there is really bothering you.

SPEAKER_01 18:59

Yeah, I don't know. It's not like my wrist, it's like anyway, love her.

SPEAKER_00 19:05

And her kitchen.

SPEAKER_01 19:07

Oh my god. That kitchen is what dreams are made of.

SPEAKER_00 19:16

It is, it's a very nice kitchen. Uh very updated now, too.

SPEAKER_01 19:20

Yeah.

SPEAKER_00 19:21

I have a hidden fridge. But no fridge water, I couldn't help but notice.

SPEAKER_01 19:28

It might be on the side.

SPEAKER_00 19:30

I looked.

SPEAKER_01 19:30

On the inside?

SPEAKER_00 19:31

Yeah, I looked. I couldn't find it. I mean, he'll he'll let us know for sure after listening to this. Yeah. If there's fridge water. Um, hidden shoes, hidden shoe drawer.

SPEAKER_01 19:40

Yeah, we need that. I'm taking notes.

SPEAKER_00 19:43

The place is great. Of course, his father is really great too. Is it like getting worse as we're recording here? Or I'm just like the food was amazing.

SPEAKER_01 19:53

We just had leftovers.

SPEAKER_00 19:55

It was Indian food. It was oh my god, it was so great. I I saw the big tubs come out from the guy like the caterer, and I just hoped and dreamed that it would be everything it was, and it exactly was. And I just could not get enough. It was Eddie Four Bowls presented, I think it was actually three, but he did for the moniker, you know.

SPEAKER_01 20:20

We took a lot of leftovers home. Well, we were because we like each had a container, and then Pooja was like, no, take more. And we couldn't be rude, so we had to take more.

SPEAKER_00 20:29

Of course, we're gonna take more. So we had a very late lunch, early dinner here today, which I'm not upset about. I'm probably gonna have more in two hours because why not? It's a great time. That place is awesome. Too bad it's far away from us in what seems like north central Jersey. Because that stinks.

SPEAKER_01 20:50

Oh, Pre said it was by Karthick's house.

SPEAKER_00 20:54

In like north central Jersey.

SPEAKER_01 20:56

Oh, wait, where does he live?

SPEAKER_00 20:59

He lives in north central Jersey. Yeah, he lives that's like about where he lives. He lives somewhere over there. I'm not gonna tell people a town where they can look up Carthic and this specific town. So, um, but he lives up there, yeah. Not proximity.

SPEAKER_01 21:18

I have his address.

SPEAKER_00 21:20

You certainly do have his address. Is that a threat?

SPEAKER_01 21:24

We need to make sure that no. We need to make sure we get all these people are moving and we need to make sure we get their updated addresses to make sure that they get a Christmas card this year.

SPEAKER_00 21:35

That's a good point. Yeah.

SPEAKER_01 21:36

I love a Christmas card. I can't wait. I know it's practically July. But I just love Christmas card season.

SPEAKER_00 21:46

Well, when would you define Christmas card season?

SPEAKER_01 21:48

Like Christmas time.

SPEAKER_00 21:49

Oh. Yeah, you do look forward to um we have to get a photo with Ollie.

SPEAKER_01 21:54

Yeah, we do.

SPEAKER_00 21:55

Somehow.

SPEAKER_01 21:56

We'll get our brother Vanessa to take a picture of us.

SPEAKER_00 22:00

Oh yeah, that'll go really well. Well didn't you already have a mock-up or was that last year's? That was last year's Christmas card.

SPEAKER_01 22:07

Yeah.

SPEAKER_00 22:08

Yeah. Now we have um have yet to get our what I assume will be our Christmas photos. Any other things that are firing you up or you find yourself passionate about?

SPEAKER_01 22:25

Thinking about any like mildly strange encounter when I was walking to the dentist the other day and some freak was walking by. Ironically, I was walking to the dentist and then he goes, smile, sweetie. So then I like do this like ugly smile where you just like roll your top lip up and then kind of like suck in your bottom lip. So I did that.

SPEAKER_00 22:56

Yeah, you were you've been waiting to to launch that one at the right moment.

SPEAKER_01 23:00

I have been, and I felt like that was the right moment.

SPEAKER_00 23:03

I'm really happy you got to. It's crazy how fast this happens when I'm not with you. It's like literally you step outside. This happens.

SPEAKER_01 23:11

My like outfit was really cute though, so like I don't blame the guy, you know.

SPEAKER_00 23:15

Well, you know, to make this a better um yes, people, this does happen. I have a lot of people who now like.

SPEAKER_01 23:22

Oh wait, it doesn't happen. What did um what happened? Oh, when you were in Portland, I was walking Ollie one morning, and there was this disheveled, disgruntled man who may or may not have been on some sort of substance, like across down the street and then across the street from us, and we were turning, so like we weren't running into him, but he was just like yelling at nothing kind of a thing, and then he like saw me and Ollie, and he starts like cursing at me and him, and he's like, F you, you and your little dog with your pretty face and your little dog, and to be like, Oh, so you think I'm pretty?

SPEAKER_00 24:10

You are a true local now. You even gave directions today.

SPEAKER_01 24:13

Oh my god, I did. I gave directions for one straight over today.

SPEAKER_00 24:18

It's a good first step.

SPEAKER_01 24:20

Yeah.

SPEAKER_00 24:20

Next to telling people where Independence Hall is. Um, what else was I gonna know? I wanted to say something.

SPEAKER_01 24:28

Oh, I was drinking water at pre people are so weird. Although no one said anything. So I was drinking water at baiting people too. I was I wasn't baiting anyone. I was just drinking water like a normal human. And another married woman next to me was also drinking water. No one said or thought a dang thing about her. I know. So I'm drinking water, and then well, you come over and you're like, here, they had an NA, like a non-alcoholic beer, if you want that. And I was like, no, like I'm good with water, whatever.

SPEAKER_00 25:06

Because of the migraines, yeah.

SPEAKER_01 25:09

Also, people are allowed to just drink water, and you don't need a reason to, you can just drink water because humans need to drink water anyway. So then you were like, All right, everyone, like no one said anything. And then Eddie goes, It's not because she's pregnant, it's because she gets migraines. And like Caroline and Sam were like, Oh yeah, no, like we we weren't gonna say anything, and then it wasn't for them. It wasn't for them, Chris, who was a respectable person and didn't say anything. And then I like made a joke because you brought me back two waters, and I was like, Oh, great, good for the fetus. And he wasn't there when this initially happened, and he got so excited.

SPEAKER_00 25:50

He did get it.

SPEAKER_01 25:51

He was like, Oh, really? I wasn't gonna say anything. I appreciate you not being a total freak.

SPEAKER_00 26:00

He's a really great guy. Um, I'm glad he had the social awareness in that moment. He did get so excited. I like heard it from afar because I like walked away to go do something else. Because I was DJ for this party. Oh my god. I had like the crossover between like between instrumental, cultural, Indian music from Kartick's father. And he's like, wait, wait, wait, how do I get the how do I get the speakers on the house to link up to Mike's speaker? And I was like, I that's a great question. I'm not sure how we do that. And he's like, Okay, cool. Why don't you play this playlist? And I was like, is it just gonna play or like what do I need to like mix in a couple other things? And he's like, no, see, it's an hour and seven minutes. We at least have an hour before we have to decide what other music is gonna play. I'm like, all right, that's great. This is what I wanted. There were many people who were Indian at this party, it's it seemed right, especially for dinner. So then Karthik comes up to me five minutes later, and he's like, What music is this?

SPEAKER_01 26:59

Well, then Pree comes up separately and was like, Are you DJing? She's like, I was wondering how this ancient Indian music started playing.

SPEAKER_00 27:09

And I'm like, I don't know what to do. And Karthik's like, Well, you have permission from me and my mom to change the music. And I was like, but what about your father? We were bonding over this. And so then I'm caught between two people and I played a couple, like, you know, like really like high dentist music, high-end dentist music. So basically, my shiny teeth and me by Chip Skylark. And brush your teeth by the wiggles. And brush your teeth by the wiggles. And they loved it. They were singing.

SPEAKER_01 27:40

Yeah, because they're all dorks.

SPEAKER_00 27:42

Yeah, and then I found my niche and I was like, all right, I'm gonna play like SpongeBob tunes. And then they started singing and dancing at the table, and I was like, I really I scratched this itch in their ear. I was like, right, this is my audience right now. And it worked out really well. Congrats to them. Beautiful event. Happy we win.

Wrap-Up How To Reach Us

SPEAKER_00 28:00

So thank you for coming back to another episode of Your Checkup. Hopefully, you were able to learn something for yourself, a loved one, or a neighbor. You can send us an email, you can find us on Threads, follow us on Instagram, or leave us some fan mail. But most importantly, stay healthy, my friends. Until next time, I'm Ed Deleski. I'm Nicole Rufo. Thank you, goodbye. Bye. This

Medical Disclaimer

SPEAKER_00 28:27

information may provide a brief overview of diagnosis, treatment, and medications. It's not exhaustive and is a tool to help you understand potential options about your health. It doesn't cover all details about conditions, treatments, or medications for a specific person. This is not medical advice or an attempt to substitute medical advice. You should contact a healthcare provider for personalized guidance based on your unique circumstances. We explicitly disclaim any liability relating to the information given or its use. This content doesn't endorse any treatments or medications for a specific patient. Always talk to your healthcare provider for a complete information tailored to you. In short, I'm not your doctor. I am not your nurse. And make sure you go get your own checkup with your own personal doctor.