New Medicare GLP-1 Program: Weight Loss Drugs for Just $50/Month?

A major Medicare announcement could make certain GLP-1 medications much more affordable for eligible beneficiaries.

In this episode of the I'm With Amanda Medicare Podcast, Amanda explains the new Medicare GLP-1 Bridge Program scheduled to begin July 1, 2026. Eligible Medicare beneficiaries may be able to access select GLP-1 medications for a flat $50 monthly copay.

Amanda breaks down:

✅ Who qualifies for the program
✅ The three eligibility pathways
✅ BMI requirements explained
✅ Which medications are included
✅ Why Ozempic is not part of the program
✅ How the application and billing process works
✅ Whether the program makes sense if you're near Medicare's annual prescription drug spending cap
✅ Important considerations before talking with your doctor

If you've stopped taking a GLP-1 medication because of cost—or are curious whether this new program could help—you won't want to miss this update.

For Medicare questions, visit:
https://www.imwithamanda.com

#Medicare #GLP1 #Wegovy #Zepbound #MedicarePartD #WeightLossDrugs #Medicare2026 #SeniorHealth #PrescriptionCoverage #AmandaMedicare

Information discussed in this episode is based on currently available details and may change as additional guidance becomes available.

00:00 Introduction & Breaking Medicare News
00:40 What Is the Medicare GLP-1 Bridge Program?
01:32 Program Start Date & Duration
02:00 Who Is Eligible?
02:36 Pathway #1: BMI 35 or Higher
03:23 Pathway #2: BMI 30-34 Plus Qualifying Conditions
04:11 Pathway #3: BMI 27+ Plus Additional Conditions
05:08 Which GLP-1 Medications Are Covered?
06:06 Why Ozempic Isn't Included
07:08 First Steps: Talk With Your Doctor
08:05 How the Billing Process Works
09:28 Understanding the $2,100 Part D Cap
11:20 Who Benefits Most From This Program?
13:05 Planning Ahead for 2027 Coverage
14:02 Potential Growing Pains With a New Program
15:02 Final Thoughts & Key Takeaways
16:10 Contact Information & Podcast Wrap-Up

Transcript

SPEAKER_00 0:10

Hello everybody, welcome to another episode of the On with Amanda Medicare Podcast. Um, coming to you with some breaking news today. Um, a lot of talk in the broker world. Um, I don't know how much has seeped out into the consumers yet. So I'm excited to tell you about the Medicare GLP1 Bridge program. Um, what the heck is that, right? GLPs, wow, those are expensive. I don't know if those are for me. Um, hopefully I bring you some good news today. So the GLP1 Bridge is a CMS or Center for Medicare Services run program. Um, they're calling it a short-term demonstration that they're going to offer that will provide certain GLP1 medications to Medicare beneficiaries who have Part D at a copay of $50 a month. Yes. $50 a month. So no deductible, none of those coinsurances that you run into with Part D this year. Um, it will provide those specific GLP1 medications with a $50 copay. When does this start? Um, the program is scheduled to begin July 1st of 2026. So we're just about a month out from uh this program going live and hopefully helping people. Um, it's going to run through the end of 2027. So July 1st of 2026 through next year, it will end the end of December 2027. Um, there's obviously some eligibility requirements for this. So really two different things. There is a requirement that you do have Medicare Part D, either standalone Part D, either Medicare Advantage with Part D prescription drug coverage, a special needs plan. Um, as long as you have a Medicare Part D plan, you are eligible if you meet the clinical criteria. So Medicare is uh published three different clinical pathways, they're calling them. Um so if you have Part D and you meet one of the three following pathways, then you would be eligible to receive one of these covered medications for $50 copay. I'm gonna share those pathways with you now. Okay, so pathway one, pretty simple, very straightforward. Um if you have a BMI or body mass index above 35, so 35 or higher, that is the only qualifying criteria that you would need to be eligible for this program. So I put my least favorite graphic of all time, the BMI chart. I know it's not super uh generous, but you'd see here, you know, right around this line, this uh, you know, 35, 36, right around here. Um, if your BMI is in that range, then you don't need additional diagnosis to qualify for this program. The second pathway would give you a little bit more flexibility on your BMI, so from 30 to 34. Um, if you also have a qualifying condition, so hypertension, um, there are specific, you know, ranges of that, or a diagnosis of heart failure or kidney disease. So if you have one of those qualifying conditions and your BMI falls between 30 and 34, you are eligible for this program. The last, so third and final pathway would be a BMI as low as 27, um, would go up to 35, because remember, above 35, you don't need another qualifying condition. So 27 and up, um, there's some additional qualifying conditions that would make you eligible for this program. Um, pre-diabetes, previous history of myocardial infarction, that's a fancy word for heart attack. Um, a previous stroke or symptomatic peripheral artery disease. So if your BMI is, you know, lower than 35 all the way down to 27, but you have one of these additional diagnoses, then this program would be eligible for you. What medicines are covered? So I want to take a quick second. Um, there's a lot of information about this online. I I really kind of consolidated it all here to make it easy. Uh, the first one is one I haven't heard of this Foundado in any formulation would be an eligible medication um with a $50 copay. Wagovi is on this list. That would be all formulations. So whether it's an injection or an oral pill, um, that would be eligible for coverage under the GLP1 bridge program. ZephBound is also the is the third option. Um ZeppBound is only going to be offered through this program in the quick pen version, meaning you get one pen that you can take the dose out of each week. Um, it wouldn't be individual vials and it wouldn't be in an oral form. But these are the three medications that uh would be eligible. So we listed the found AO, the Wagovi, and the Zep Bound. What about Ozempic? Um, Part D is actually much more favorable of Ozempic, so I wouldn't be surprised if someone says, man, I wanted to try ZEPBON, but my formulary would only allow Ozempic. Um, Ozempic is not a covered medicine in this program. So it would be important that you talk to your doctor. And that's really my first recommendation for first steps. Um, talk to your doctor about GLP ones. Are they, do you meet one of the pathway criteria? Um, is a GLP one something that's suitable for you? If the answer is yes, then you can have a conversation with them about those three medications. Um, how is billing gonna work, right? Wait, how will they even know that I only owe $50 for this medication? Um, the prescribing doctor is gonna have to send out or fill out the necessary documentation and paperwork to qualify for you, to qualify you for this program. Um, but once that is approved and the prescription is with the pharmacy, um, the pharmacy is actually going to have a completely separate account that they bill for coverage of these claims. So that means it's not gonna go through your Part D plan. Your Part D plan, whoever you have that insurance coverage with, doesn't have to also approve you for this medication. They're really out of the loop on this. This is a separate, right, short-term demonstration that's being offered through and run by Center for Medicare and Medicaid Services. Um, so a couple things that are important to know about that. If you participate in this program, the $50 a month that you pay for that GLP1 medication, whichever one you pick, will not count toward your Part D $2,100 max out of pocket. Um, so at this point in the year, I think that if uh somebody has been filling those prescriptions, they've probably accumulated a fair amount of cost towards that $2,100 cap already. So the first step would be, you know, talk to your doctor about it. But I also encourage you to just uh call your member services number um or look for your next explanation of benefits. I know it's very tempting to just toss that in the in the waste paper basket. Um, but there's gonna be information there about how much you have already accumulated towards that $2,100 cap. So if you're close to that, it may actually be better to just keep the same route that you've been taking, right? Fill it through your Part D plan, get to the $2,100 cap, because then it would be zero, as would all the rest of your medications. Um, but if you're somebody who maybe stopped taking a GLP one because of the considerable increase in the cost from 2025 to 2026, um, this could be a great option to restart that treatment without having to worry about that super high first payment because of the deductible and then the higher than previous year costs because of the coinsurance uh function of Part D. Um if you are somebody who, you know, is close to that $2,100 cap, um, then this program probably isn't gonna help you for this year. But I do want you to take that into consideration for next year. Um, this program is gonna run through 2027. So as you explore your coverage options for 2027 during the annual enrollment period, right? We're already gearing up for it. Um, keep in mind that there is a more affordable way to receive these medicines, which might have an impact on the planned decisions that you make. Um, so talk to your doctor, connect with your insurance company. A simple call to member services would uh give you the opportunity to ask them where you are in your Part D max out of pocket, right? It's the $2,100 cap. If you're super far from that $2,100, this program would be a better option. If you're close to it, um that that's a consideration. But um call them, they'll let you know what that is, or take a look at your next explanation of benefits. The last thing I want to say about this program, this is new. Um, this has never happened before. So, with at like with any new program, um there's certainly gonna be some growing pains, right? The Center for Medicare Services is involved, your pharmacy is involved, your provider's involved. Um, no one's really worked with the program before. So just plan on being a little bit patient as things work through. But from all the reading that I've done, um it does seem pretty cut and dry and clear. So if you have a Part D plan, if you meet one of the three pathways for um the criteria, then one of those three medicines should be available to you at a $50 copay. Um, exciting news. I know a lot of people, you know, have mixed feelings about GLP ones. That's why I think it's important to talk to your doctor. Um, but this is certainly a more affordable way for people to um address that that GLP1 concern than what we currently have with just the Part D for this year. So I hope that helps. Um, I'm sure that there's gonna be questions. You can reach us at info at I'm withamanda.com. Um I also hope that you will like this episode. Um, share it wide. Um, it will help a lot of people. So proud to bring this to you today. Again, this is a new program. This is what I know about it so far. Details are still evolving. Um, but thank you for taking the time to listen. Thanks so much. Thanks for listening to another episode of the I'm with Amanda Medicare podcast. Please make sure to subscribe wherever you get your podcast so you don't miss an episode. Also, please leave a review as that helps you reach more people that can benefit from this podcast's content. If you have questions or topics you want me to cover for a future episode, please email them to info at iMwithAmanda.com. I look forward to hearing from you. Like any good industry, we do have compliance requirements. So here's my disclosure. We are not a government agency. We are licensed insurance agents who discuss insurance programs such as Medicare Advantage, Medicare Supplements, and Medicare Part D prescription drug coverage. Any specific plan information I provide is limited to the plans I offer in your area. Please contact Medicare.gov or 1800 Medicare to get information on all of your options. Thank you.