Jarrell Weight Management Specialists

The History

Medicare has never covered medications for weight loss because of a policy decision made in 2003. Congress explicitly excluded weight loss drugs from Part D coverage of Medicare in the Medicare Modernization Act. It was largely due to, in my opinion, a stigmatization of the disease of obesity. They saw it more as a lifestyle issue rather than the chronic disease that it really is. Obesity is a chronic relapsing disease that is the underlying problem of many other diseases including diabetes, certain cancers, osteoarthritis, fatty liver disease, heart disease, and obstructive sleep apnea, to name a few. In order to have medications for the disease of obesity, it would mean there would need to be a change in the law by Congress.

Medicare GLP-1 Bridge Program

A few things changed this year with the Medicare GLP-1 Bridge program. It is a temporary federal program for patients with Medicare to gain access to GLP-1 medications for obesity. The reason it is temporary is in order to give time for the Center for Medicare Services (CMS) to develop a more long-term plan (which will be called the BALANCE model). The Bridge program starts July 1, 2026. There is a flat $50 a month co-pay for the GLP-1 medications. CMS and pharmaceutical companies, Novo Nordisk, and Eli Lilly, negotiated the coverage of four different types of GLP-1s: Wegovy injection, Wegovy pill, Zepbound injection, and the Foundayo pill. Traditionally, the cost for GLP-1 medications was around $1100/month. CMS negotiated a monthly price of $245, though the co-pay will only be $50 per month for the patient.

If you’d like the plain-language version, how the program works, who’s eligible, and how to check your own coverage, see our Medicare GLP-1 Bridge Program page.

Who Qualifies?

A patient must meet one of these criteria to qualify:

1. BMI ≥35 kg/m2, or
2. BMI ≥30 kg/m2 with one of the following: HFpEF, uncontrolled hypertension (defined as systolic blood pressure >140 mmHg or diastolic blood pressure >90 mmHg, despite concurrent treatment with two antihypertensive medications), or CKD stage 3a or above, or
3. BMI ≥27 kg/m2 with one of the following: pre-diabetes (as defined by American Diabetes Association guidelines), previous MI, previous stroke, or symptomatic PAD

It will also require a prior authorization by your doctor with monthly lifestyle, counseling, and obesity management documented.

An important piece of the puzzle is that this is not standard Medicare part D coverage. It is outside of part D and co-pays do not count towards your part D coverage. Spending does not count toward the part D out-of-pocket cap.

Why Now?

Treating chronic health conditions is expensive. When you look at previous studies and how much weight loss it would take to decrease overall costs for other chronic health conditions, it never made sense when the medicine was $1100 a month. But when it is $245 a month, it makes much more financial sense.

To get a background, we need to understand how Medicare or other insurance companies determine if a medication is worth funding. Typically, they use QALY, Quality Adjusted Life Years: how many dollars they spend per year to add one quality year to a patient’s life. In the US, that threshold grew from $50,000, to $100,000, and now caps out at $150,000. As the QALY amount grew, Medicare could now provide coverage for expensive medications that add quality years to a patient’s life. GLP-1 medications are now covered because they 1. Meet the financial requirements and 2. Add quality years to a patient with obesity’s life by improving co-existing conditions like diabetes and heart disease and reducing health care costs.

Let’s talk about a few studies that looked at the cost-effectiveness of weight loss medications of older anti-obesity medications like Contrave, Qsymia, Xenical, and Lorcaserin. Eric Finkelstein from Duke University looked at Qsymia and whether or not it was financially justified through improved healthy outcomes. They used a baseline of a $50,000 per QALY threshold. Qsymia came out at $48,340 per QALY, right under the threshold. One criticism is that this was only for one year of treatment. As has been shown in multiple different studies, when patients stop weight loss medications, they tend to regain their weight. https://pmc.ncbi.nlm.nih.gov/articles/PMC4486409

Other studies looked at Contrave and it had ~$85,000 to 150,000 per QALY. Semaglutide (Wegovy) was also looked at when its cost was around $1100 a month. Some studies quoted it at close to $300,000 to $1 million per QALY. In order for it to meet less than $100,000 per QALY it would need about a 70% to 80% price reduction at the time. Interestingly, that is roughly the price reduction we are seeing with the Bridge Program (from $1100 to $245 per month).

On top of that, the math has changed. The SELECT trial, which looked at Semaglutide (Wegovy), showed reductions in major adverse cardiac events (MACE): heart attacks, stroke, and overall cardiovascular death. MACE comes with a lot of healthcare costs. This means preventing them has a huge impact on QALY.

So to break it all down, if we want GLP-1s to become fiscally responsible then we need their price to be somewhere less than $3000-$6000 per year. At $245 per month, they would meet that goal at $2,940 per year.

Your Costs

Now that I am done with my nerdy economics talk, let’s talk about how this impacts you as a patient. If you have Medicare and you have the disease of obesity (or are overweight with pre-diabetes, a previous heart attack or stroke.) then you can start treatment with GLP-1 medications in July 2026 for as low as $50 per month co-pay. If you want to learn more about this, I have a link to Medicare’s program, or visit our Medicare GLP-1 Bridge Program page for how it works and how to check your eligibility. You can also contact our office and I’d be happy to have a consultation with you to discuss it. For many of you, you have been waiting on this moment to be able to take control of your health and now you finally can.

https://www.cms.gov/medicare/coverage/prescription-drug-coverage/medicare-glp-1-bridge

Seth Jarrell, MD