Dr. Sarah Stombaugh:
This is Dr. Sarah Stombaugh and you are listening to the Conquer Your Weight Podcast.

Announcer:
Welcome to the Conquer Your Weight Podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here’s your host, obesity medicine physician, and life coach, Dr. Sarah Stombaugh.

Dr. Sarah Stombaugh:
If you have Medicare insurance and you’ve not been able to access GLP medications previously, today is a really exciting today. We are releasing this episode on Wednesday, July 1st, 2026, and for the first time ever, we are seeing Medicare cover GLP medications for the weight loss indication. And this is so, so, so exciting. So before, let’s say you’re not 65, you’re not on Medicare, you’re thinking about passing on this episode, I would love for you to take a listen and more importantly, please share this with someone in your life who would benefit from this information. This is really exciting to finally have access to these group of amazing medications for Medicare beneficiaries. And in this episode today, you are going to learn all about what this coverage looks like because while there is coverage moving forward, there are some stipulations and we’re going to talk about what is this program, how long is it going to be in place for, how do you know if you qualify for the medications?

And then more importantly, how do you get started? How do you work with your prescriber to get that medication in hand? This episode is going to address all of those questions. So if you are a patient, if you are a prescriber, if you have a loved one who’s any of those things, please share this episode with them because I want to be able to support you in your weight loss journey. I am Dr. Sarah Stomba, board certified obesity medicine physician. And as I was saying before, this is a really exciting day in the world of obesity medicine. We have been having conversations for years with Medicare patients where it’s so frustrating because they have obesity, but they don’t yet have diabetes. Maybe they don’t have sleep apnea, they don’t have these other medical criteria for which the GLP medications have been covered. And Medicare traditionally has not covered GLP or for that matter, any weight loss medication for the treatment of weight loss on its own.

And so there’s these incredibly frustrating conversations where maybe patients have pre-diabetes or they have severe arthritis or they’ve been working on their weight loss for long periods of time. We know that they could get benefit from the GLP medications, but the only way to access them before for the weight indication has been to pay out of pocket for the medications. So from now through the next 18 months, we are going to see these medications available for eligible patients for $50 per month. And I have patients who over the last couple of years even have been really saving their money, paying out of pocket, taking that huge sacrifice to be able to afford these medications. And I am just so excited to know that we are going to be submitting prior authorizations and seeing patients get GLP medications to treat their weight. So let’s talk about what this has looked like because previously Medicare has covered GLP medications for very specific indications.

They’ve covered it for the treatment of type two diabetes. Some plans have covered it for the treatment of moderate to severe sleep apnea in adults with a BMI of 30 or higher, specifically Zepbound for that indication. Some programs have covered Wegovy for history of prior heart attack, prior stroke, major adverse cardiac events. They’ve also covered Wegovy for fatty liver disease, commonly known as MASH. And so there are patients with Medicare who’ve been getting these GLP medications, but patients who do not have those specific disease processes have not been able to access these medications for the weight loss indication. So this is really exciting that we’re finally seeing this. But let’s talk about a little what is this Medicare Bridge program? What does this mean? So the Medicare Bridge program is just that it is a bridge. So this is actually a temporary program. It’s an 18-month program that starts today, July 1st of 2026 and goes through December 31st of 2027.

During this time, CMS, the Centers for Medicare Medicaid Services is going to be evaluating what is the benefit for these medications, what does it look like in terms of how many patients are qualifying, how many patients are accessing and using these medications, how is that affecting other healthcare expenditures, other disease processes? They’re going to be gathering that data. And the goal is that we will see eventually long-term coverage for the medication. There’s a secondary program called the Balance Program, which is not yet passed, but this would be ongoing coverage for GLP medications. But you know what? Sometimes in this space, we just have to take the wins as we get them. So right now we know for the next 18 months that we do have coverage for these medications for eligible patients, and that is awesome news. Now you might be wondering, well, who are the eligible patients?

In very classic CMS Medicare fashion, they set their own criteria for these medications. So the criteria for these medications are excluding any of the currently covered medications. So we mentioned things like type two diabetes, things like heart disease, things like fatty liver disease or MASH, things like moderate or severe obstructive sleep apnea. For patients who have those conditions who already have coverage for the medications, they can continue to receive coverage through their traditional Part D plan. And if you’re someone who’s listening who’s thinking, “Well, I have those conditions, I’m not getting those medications,” make sure to talk to your doctor because even before this plan was passed on July 1st, we have had multiple patients with Medicare with those indications we’ve just talked about who have been able to access those medications for those very specific conditions. So that will stay the same. So patients who have those conditions will continue to get their medications through their traditional Part D plan.

But when we’re talking about the weight indication by itself, we know that patients with a BMI of 35 or higher will have access to these medications. Patients who have a BMI of 30 or higher will also have access to these medications if they have one of the following criteria, either A, heart failure with preserved ejection fraction, uncontrolled hypertension, meaning greater than 140 over 90 on two medications. So their blood pressure is not well controlled on two different blood pressure medications, or if they have chronic kidney disease stage 3A or more significant. So that is the patients with a BMI of 30 or higher. Then patients with a BMI of 27 or higher, they will meet criteria if they also have history of prediabetes, previous stroke, previous heart attack or current peripheral symptomatic peripheral arterial disease. So patients who meet those criteria will be eligible to the medication.

One thing I think that’s really important to point out is this is the BMI or the other diagnoses at the start of the GLP medication. So as I mentioned, I have multiple patients in my practice who’ve been paying out of pocket for these GLP medications for the last year or last couple of years for some patients, and we are going to use all of their starting information. So for example, I have a BMI or a patient who had a BMI of 40, for example, she’s been using Wegovy, she’s been using Zepbound for the last year or for the last two years, and now her BMI is, let’s say 29. We would use her starting BMI of 40 in order to cover her or to say, “Hey, this patient meets criteria for medication, but now she’s no longer going to be paying cash. We’re going to ask for coverage through this bridge program.” So you’re going to use the starting BMI, the diagnoses that were present at the start of the medication.

So if you’ve already lost weight, your BMI is now in a lower range and doesn’t meet criteria based on the current numbers, no big deal. It’s the BMI at the start of initiation of any therapy, any GLP therapy. So that is really good news and I think really, really important to point out. You want to make sure that your prescriber is aware of that because that will make a difference in whether you do or do not get coverage for these medications. So that piece, super important. We see this come up a lot in the traditional commercial insurance world as well, but that is a different topic for a different day. So patients must meet one of those different criteria. Now, what this will look like is that patients will need to get, of course, a prescription from their prescriber. And so this is something that July one, it’s really exciting, but this is not an emergency.

I think doctors, I think pharmacists, I think the drug pharmaceutical companies are going to be just inundated with requests for these medications, and we are all going to be working as fast as we can to get these prescriptions turned over for patients. What I would recommend is that if you have not had an appointment specifically about your weight recently, I would, if you are a patient, schedule a appointment with your physician to talk about this specifically and have your doctor submit a prescription when you’re there right together in front of one another. You can get prescription for any of the GLP medications that are indicated for the treatment of obesity. And as I say that, it is Wegovy, both the tablet and the injection and all of the doses of the injection, including the new HD high Wegovy dose. You can get the Foundayo, which is a new oral GLP medication, and you can get Zepbound, but specifically in the KwikPen formulation.

So Zepbound is available in three different mechanisms of injection. There is the auto-injector, which is the single dose pen. There is the vial, which is the original cash pay option. And more recently, earlier this year of 2026, they rolled out the KwikPen, which is a multi-dose Zepbound pen. This KwikPen is the version that is going to be eligible for the Medicare GLP Bridge program. So you’re going to make an appointment with your prescriber and they will need to prescribe one of these medications. If you are brand new to these medications, you should be prescribed the starting dose of medication. If you have been on these medications, obviously you should just continue at the dose that you’re on, but you’re now potentially getting it from a different pharmacy. We’re going to be seeking prior authorization, so the costs will look different, but you’ll continue where you’ve been in that journey.

But let’s say you were on Zepbound vials, for example, in order to continue the Zepbound medication, you’ll have to switch to the Zepbound KwikPen, which no big deal, pretty easy transition, but you’ll just want to make sure that you’re getting that prescription specifically for the KwikPen because the other formulations of Zepbound will not be covered under the Medicare GLP Bridge program. So that will be sent into your pharmacy. That could be any traditional pharmacy, your CVS, your Walgreens, your mom-and-pop pharmacy, your local grocery store pharmacy, whichever your preferred pharmacy is. You can also do certain mail order pharmacies. Both Eli Lilly has their Lilly Direct Pharmacy and then Novo Nordisk, the company that makes Wegovy has the NovoCare pharmacies, so prescriptions can also be sent to those as well. So initially, the pharmacist will have to submit this specifically to the Medicare GLP Bridge program.

What’s really important here is that this is separate from traditional Part D drug coverage. So this is its own separate entity and the cost for this medication is going to be $50, which is really exciting. Unfortunately though, that $50, because it is not part of your traditional Part D plan, is not going to apply to your out-of-pocket maximum, for example. It’s not going to be eligible for the prescription savings program where people divide their payments for their prescriptions across every month. It’s not eligible for any sort of coupons or any sort of low income discount. The cost is $50 for every single person regardless of their circumstances. So in some ways that’s great because it’s very simple and straightforward, but of course that may be challenging for some people to afford that out of pocket. What is absolutely true is that this is a huge deviation from the $300 to $500 per month that we’ve been seeing for these medications.

So really exciting to finally have it available at that $50 per month option. So the pharmacist will need to submit this specifically to the Medicare GLP Bridge Program. Your doctor will then need to do a prior authorization. This is very common for these type of medications. Honestly, in today’s world, very common for a lot of medications. This process typically takes 24 to 72 hours. My understanding from everything that we’ve read so far is that patients who meet criteria should get an automatic approval if the prescriber is doing an electronic prior authorization. There’s an online program called CoverMyMeds where they can go through and answer questions to show that a patient meets criteria. So patients who clearly meet criteria should get automatic approval. Fingers crossed on this. It’s before July 1st as I’m recording this, and so I’ve not yet had the opportunity to fill out this paperwork.

I can send any updates and leave those in the comments if anything ends up being different. But there will be that automatic denial from the pharmacy. They will initiate the prior authorization. Your prescriber will do the prior authorization, which may take a couple of days both to just do it because there may be quite a few other patients for whom they’re also filling out this paperwork on top of their regular clinical responsibilities, as well as then if there is any sort of delay, if there’s not just those automatic approvals, there may be a couple of days delay before we see approval, which is very common, excuse me, very common that we might see those type of delays. So typically a couple of days and then you either are approved if you meet criteria. The approval criteria are very straightforward. If you do not meet the criteria that we were talking about before, you’ll not have coverage for this medication, but if you meet criteria, that is great news and we are expecting these automated approvals.

Once you have that, you’ll be able to go to your pharmacy or if it’s a meal order pharmacy, they will start the process to send that medication to you. You’ll go to your pharmacy, you will pay the $50 copay, and then you’ll be able to walk away with medication in hand, which is really, really, really exciting. Couple of things that I want to mention, just little tidbits and side facts. So the Zepbound KwikPen, as I mentioned, Zepbound comes in three different formulations. The KwikPen is a four-dose multi-pen that does also require a prescription for needles. This has been a frustration for some people because maybe they’ve gotten a Zepbound KwikPen, but they’ve not gotten the needles that you need to use to inject the medication. Your prescriber can either send a prescription for needles. These are available over the counter, but a lot of pharmacies will require a prescription in order to dispense them.

You can also go to a lot of online retails. So for example, you can go to Amazon Pharmacy, you can search pen needles. A lot of times they’ll be labeled as insulin pen needles. This mechanism is identical to a lot of insulin pens. And so an insulin pen needle, a pen needle, those are interchangeable and you can look for a. We traditionally will prescribe a 31 gauge. The higher the gauge, the smaller. So a lot of times people prescribe 29 gauge, 30 gauge, maybe 31 gauge, and anywhere from five millimeters to half an inch. So a couple different sizes, but all the pen needles are interchangeable. And make sure you talk to your prescriber about that because I’ve gotten comments from other listeners. There’s nothing more frustrating than coming home with your medication than realizing that you do not actually have the needles to be able to inject that medication.

So that is one important note. Another note, we talked about the eligibility criteria. I think one of the biggest frustrations is there are people who are not going to be eligible. So while this is opening up coverage for many, many individuals, this is not opening it up for every single person. When we look at the FDA approved criteria for these medications, we’ve traditionally seen that a BMI of 30 or higher regardless of comorbidities has been covered. So in CMS, they’re requiring a BMI of 35 or higher. So there may be patients who would be really pretty decent candidates for GLP medications. Let’s say someone had a BMI of 33 and they didn’t have any comorbid conditions, or maybe they do have a couple of other health conditions like blood pressure, but it’s pretty well controlled on one or two medications. Maybe they have high cholesterol, maybe they have arthritis, they have other conditions associated with their weight.

That is going to be incredibly frustrating because there are going to be patients that fall through the cracks here and do not meet coverage criteria. Now, it doesn’t mean that you can’t access these medications through the current mechanisms, which are different cash pay options. The coverage for GLPs is great, but there’s also non – GLP medications indicated for weight that can be incredibly helpful. This is something that we do very commonly for patients either in combination with GLP therapy or as single therapy for patients who don’t have coverage and can’t afford to pay out of pocket for the GLP medications. So other medications like Metformin, like Contrave, which is bupropion plus naltrexone, like Qsymia, which is phentermine plus topiramate, there are other options for these medications or for similar type of medications that may be beneficial because like I said, one of the frustrations is that there are some people who may traditionally meet criteria when we look at the FDA approved criteria for these medications, but are not going to meet it based on the Medicare GLP Bridge program.

But I hope this was helpful. Let me know. Drop any questions that you have in the comments. I’m going to be posting a lot of content over the next couple of days as I go through this process for my patients, letting you know what it has looked like as we start to see approvals. I am going to start sending prescriptions first thing on the morning of July 1st, and so really exciting to share those updates. But any questions that you have, please drop them in the comments. If you are not already a subscriber to my YouTube channel, I would so appreciate you joining me, following along because I love sharing these type of updates and supporting you during your weight loss journey. Please share this episode with someone who you think would really benefit from it. I so appreciate your support. I will see you all in next week’s episode.