Who Qualifies for the Medicare GLP-1 Bridge?

To use the Medicare GLP-1 Bridge, you must meet all four of the requirements below. Missing any one of them disqualifies you.

1. You have Medicare Part D drug coverage

Qualifying coverage includes:

• A standalone Medicare drug plan (PDP)
• A Medicare Advantage coordinated care plan with drug coverage (MA-PD), including HMO, HMOPOS, and Local or Regional PPO plans
• A Special Needs Plan (SNP)
• An employer or union group waiver plan (EGWP)
• The Limited Income Newly Eligible Transition (LI NET) program

You are not eligible if your only Medicare coverage is a private fee-for-service plan, a cost contract plan, or a PACE organization. If you are not sure what you have, call 1-800-MEDICARE (1-800-633-4227).

2. You are not already getting a GLP-1 through your Part D plan

If your Medicare drug plan has been paying for a GLP-1 drug for any reason, keep getting it through your plan. You cannot move it to the Bridge.

3. You do not have a condition that Part D already covers a GLP-1 for

Medicare's prior authorization form is explicit that a GLP-1 request must be sent to your Part D plan rather than the Bridge if any of these apply:

• Moderate to severe obstructive sleep apnea (OSA)
• Noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) with moderate to advanced liver scarring (fibrosis). This was formerly called NASH, and it is what Medicare.gov describes in plainer language as "fatty liver disease."
• Type 2 diabetes
• Established cardiovascular disease, where the GLP-1 is prescribed to reduce the risk of major adverse cardiovascular events

This is not bad news. It means your own drug plan may already cover a GLP-1 for you, and those costs do count toward your deductible and out-of-pocket limit. Contact your plan and ask.

4. You are 18 or older and meet a BMI threshold

You need to meet one of these three combinations when you start GLP-1 therapy:

How Medicare defines these terms

• Uncontrolled high blood pressure: systolic above 140 mm Hg or diastolic above 90 mm Hg, despite treatment with two blood pressure medications.
• Prediabetes: as defined by American Diabetes Association guidelines.
• Diastolic heart failure: heart failure with preserved ejection fraction.

Important BMI note: the BMI that counts is your BMI at the time you started GLP-1 therapy. If your BMI has already come down since starting a GLP-1, your initial BMI is the one used.

BMI is calculated from your height and weight. Ask your doctor for yours, or use the NHLBI BMI calculator.

Not eligible? Other ways to save

• Check whether the drug manufacturer offers a patient assistance program.
• Check whether your state has a pharmaceutical assistance program.
• Compare mail-order pharmacy pricing.
• Compare cash prices on drug discount sites. Note that discount cards are not creditable coverage and payments made with them do not count toward your Medicare deductible or out-of-pocket maximum.

Medicare also has an eligibility questionnaire you can walk through in a couple of minutes.

More on Medicare and GLP-1 drugs

• What Is the Medicare GLP-1 Bridge Program?
• Which GLP-1 Drugs Does Medicare Cover?
• What Do GLP-1 Drugs Cost Under Medicare?
• How Do I Get GLP-1 Coverage Through Medicare?

Questions?

Call or text our Medicare team at (312) 726-6565, or call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Compare Medicare plans and get a quote

Sources

• Medicare.gov - Weight loss drugs
• CMS.gov - Medicare GLP-1 Bridge
• CMS Product No. 12234 - Medicare GLP-1 Bridge fact sheet (PDF)
• CMS - Medicare GLP-1 Bridge Prior Authorization Request Form (PDF)

This article is general information, not medical or coverage advice. Talk with your doctor about whether a GLP-1 drug is right for you, and confirm your own eligibility with Medicare.