Medicare patients can get GLP-1s as of July 1

Medicare beneficiaries for the first time will be eligible for coverage of breakthrough GLP-1 weight-loss medications after years of struggling to get the drugs to more seniors.

Starting July 1, eligible patients can get GLP-1s to treat obesity for just $50 per month as part of a test program for Medicare, the social safety net health insurance program for seniors over age 65.

Medicare Part D, the prescription drug benefit program, already covers some GLP-1 medications for conditions including Type 2 diabetes and heart disease, but federal law prohibits coverage solely for obesity. 

Earlier this year, the Trump administration’s Center for Medicare & Medicaid Services, headed by Dr. Mehmet Oz, created a temporary demonstration program that sidesteps the law to allow more beneficiaries to access GLP-1s, including those who are overweight with conditions such as prediabetes and uncontrolled high blood pressure. 

The Medicare GLP-1 Bridge is a temporary pilot program that begins on July 1 and is scheduled to last through 2027. It was formulated as part of the Trump administration’s “most favored nations” drug price negotiations, in which U.S. patients are charged at the lowest price comparable to other developed countries. 

Bipartisan groups of lawmakers, most of whom are either physicians or healthcare providers by training, have attempted to advance legislation to change GLP-1 medication coverage for Medicare seniors, but the move has been seen as too costly.

The new program could give millions of seniors access to Eli Lilly’s Mounjaro and Zebpound as well as Novo Nordisk’s Ozempic and Wegovy, which have been proven to reduce the risk of heart attacks, strokes, and other chronic conditions. 

But the experiment could be short-lived if the program is not extended beyond 2027 or if private insurance companies that manage Medicare benefits do not begin covering the medication under other CMS carveouts.

Here is everything you need to know about how patients can access the medications and what it means for Medicare in the long term.

Only certain Medicaid enrollees are eligible. To qualify, a Medicare enrollee must be enrolled in a Part D drug coverage plan and meet certain health criteria when they start taking the GLP-1 medication. 

Patients with a body mass index of 35 or more qualify. Those with a BMI between 30 and 35 must have another co-occurring condition to qualify, including uncontrolled high blood pressure, prediabetes, a previous stroke or heart attack, blocked arteries in the arms or legs with symptoms, advanced chronic kidney disease, or diastolic heart failure. 

For patients with a BMI between 27 and 30, they must also have either prediabetes, a previous heart attack or stroke, or a blocked artery in the arm or leg to qualify.

Those who qualify must ask their doctor to send a prescription to their pharmacy and then complete a prior authorization form.

Eligible enrollees will pay $50 for a month’s supply of the drug, but that copayment does not count toward their annual deductible or out-of-pocket maximum.

CMS has not yet shared cost projections or enrollment estimates for the program.

An estimated 13.3 million Medicare enrollees meet the BMI criteria to qualify for GLP-1 coverage under the Food and Drug Administration rules, according to the health policy think tank KFF. But only about 4 million qualify with the additional eligibility criteria for the bridge program.

Chris Klomp, CMS’s director of Medicare and lead negotiator for the MFN drug pricing deals, said at an Aspen Institute event in June that he’s expecting the pilot program to be cost-neutral over a 24-month period. He also said he expects the number of Medicare beneficiaries who will participate in the pilot program to be within the single-digit millions initially.

“We’ll see where it scales over time,” Klomp said.

Klomp was nominated last week by President Donald Trump to fill the role of deputy secretary of the Department of Health and Human Services and is awaiting Senate confirmation.

It’s unclear what will happen at the end of 2027 when the bridge program expires. 

CMS originally planned for the Bridge pilot program to last only six months as a transition to a longer-term program called Balance, which would have shifted responsibility for covering the drug from the federal government to private insurers facilitating Part D plans. 

But insurers, including CVS and UnitedHealthcare, declined to participate in the long-term project voluntarily due to anticipated cost concerns. 

In theory, GLP-1s could, in the long term, reduce overall healthcare costs because patients no longer require expensive treatments or hospitalizations for severe chronic conditions. But the data thus far have not supported the conclusion that GLP-1s pay for themselves, at least in the short term.

Bipartisan groups in both chambers of Congress have pushed for the passage of the Treat and Reduce Obesity Act, which would lift Medicare’s ban on obesity drug coverage, but the Congressional Budget Office estimated in 2024 that doing so would increase federal spending by $35 billion over nine years.

Even with lower negotiated prices by the Trump administration from Eli Lilly and Novo Nordisk, GLP-1s are unlikely to be a cost-saving measure for the Medicare program, according to a May analysis by the University of Chicago.

The analysis found that expanded GLP-1 coverage would cost nearly $66 billion over 10 years but would save only $18 billion through reduced hospitalizations and chronic disease care, resulting in a net total of $48 billion in new spending.