Starting Wednesday, eligible Medicare beneficiaries can get GLP-1 obesity drugs for a $50 monthly copay through a new Bridge demonstration program. The temporary coverage, set to expire at end of 2027, could unlock millions of new patients for drug makers Novo Nordisk and Eli Lilly. However,…
Millions of older Americans enrolled in Medicare are about to receive a benefit that has never existed before: coverage of prescription drugs for obesity. Starting Wednesday, eligible beneficiaries can obtain GLP-1 medications to treat obesity with a copay of just $50 per month. This represents a watershed move that could unlock a vast new patient population for drug manufacturers Novo Nordisk and Eli Lilly and dramatically expand access to medications that were previously out of reach for many individuals aged 65 and above.
Medicare Part D, the prescription drug plans, already cover some GLP-1 drugs for conditions such as diabetes and cardiovascular disease. However, federal law had previously banned coverage solely for obesity. Medicare's new Bridge demonstration program sidesteps that law to cover the drugs for obesity, at least temporarily, for more beneficiaries. This includes those who are overweight with conditions like prediabetes or uncontrolled hypertension.
Under the Bridge program, eligible patients include those with a body mass index BMI of 35 or higher, as well as some people with lower BMIs who have at least one related condition. Those conditions include prediabetes, a previous heart attack or stroke, or blocked arteries in their arms or legs. The eligibility criteria open the door to many patients who previously had no Medicare coverage option for obesity drugs.
Dr. Holly Lofton, director of the Medical Weight Management Program at NYU Langone, called the criteria appropriate and broader than what she has seen with commercial insurance. She noted that the inclusion of people with prediabetes represents an effort to prevent diabetes in the Medicare population, which will ultimately reduce healthcare costs nationally.
Importantly, people who already have coverage of a GLP-1 from their Part D plan for a use already covered by Medicare, such as Type 2 diabetes, cardiovascular disease risk reduction, or sleep apnea, do not qualify for the Bridge program. Those patients will continue to access the drug through traditional coverage.
The GLP-1s that can be prescribed for obesity under the program include Novo Nordisk's Wegovy injection and the drug's tablet form, as well as Eli Lilly's rival pill Foundayo and its obesity shot Zepbound in the KwikPen formulation. Lilly chose to only include that form of Zepbound in the program because it contains a month's worth of doses in one pen, making it easier for providers to administer, said Ilya Yuffa, president of Lilly USA and global customer capabilities.
The $50 monthly copay is significantly less than what patients without any insurance coverage for obesity drugs typically pay. That price also applies to all doses rather than increasing with a larger dosage, as it does for people paying out of pocket. Lilly and Novo have both rolled out sweeping cash discounts for their respective drugs for patients willing to pay out of pocket, but those prices can still be unaffordable for some people.
Novo Nordisk's Wegovy injections range in price from $199 for a lower dose for the first two months under a limited-time offer, to $399 for the newly launched highest dosage. The KwikPen and single-dose vial formulations of Lilly's Zepbound cost from $299 to $699 per month, depending on the dose. At the highest dosages, Novo Nordisk's daily Wegovy pill costs $299, while Lilly's rival Foundayo tops out at $349.
Crucially, the $50 monthly copay for GLP-1s will not count toward a patient's Part D deductible, or the $2,100 annual out-of-pocket cap on prescription drug costs. This detail was explained by Rachel Schmidt, a research professor at Georgetown University's McCourt School of Public Policy. Many older people may still not be able to afford an extra $600 a year for another prescription, especially as they grapple with rising healthcare costs. A quarter of Medicare beneficiaries had an income below $24,600 in 2024, according to KFF, a health policy research organization.
Still, the coverage is going to improve access to so many Americans who need these medications, and either are going without or using their hard-earned money in retirement to pay for them, according to Dr. Holly Lofton.
The Bridge program is available to Medicare beneficiaries with Part D coverage, but private insurers running those plans do not foot the bill. Bridge is funded by taxpayer dollars and beneficiary copays. Under the program, Part D plans also do not determine eligibility or approve coverage like they typically do. Instead, a healthcare provider must determine whether a person meets clinical requirements for coverage based on their body weight and health status.
The initial rollout may not be smooth. Providers must submit prior authorization requests to attest that patients meet eligibility requirements, a process some physicians said may be cumbersome. Some doctors also worry the new coverage could spark a surge in demand that will strain busy clinics and pharmacies, and others raised concerns about a lack of broader public awareness of the program.
For patients to get coverage, a provider must first send a prescription to their pharmacy. That triggers a prior authorization request for the Bridge program, which the provider must complete to certify that the individual is eligible. The provider then submits that request directly to Humana, which CMS contracted to process approvals for Bridge. Once a request gets a final sign-off, patients will pay the flat $50 copayment at the pharmacy when they pick up the prescription.
The healthcare system is already stretched thin, with many Medicare beneficiaries facing long waits for appointments with doctors, said Dr. Carolynn Francavilla Brown, a physician and vice president of the Obesity Medicine Association, the nation's largest medical organization for clinicians dedicated to preventing and treating obesity. She said after Bridge begins, doctors and specialists will likely deal with an influx of patients seeking appointments, while pharmacists grapple with an increase in prescriptions for the drugs. Patients should not expect to pick up a medication immediately on July 1, Francavilla added.
"I do think we're all going to have to be a little bit patient, because there is probably going to be a bit of a strain on clinics and pharmacies for the next couple of months as people very excitedly start these medications," Francavilla said.
Some experts pointed to the prior authorization process as a potential hurdle. Providers must submit paperwork for every patient seeking coverage, and the volume of requests could be substantial since so many people are eligible. The process could be potentially cumbersome, said Dr. Shauna Levy, medical director of the Tulane Bariatric and Weight Loss Center. But she said her clinic has already begun preparing by adding providers and identifying patients who may qualify for the program.
Francavilla noted that one potential advantage of Bridge is that it is administered through a single program rather than multiple insurance plans, which could make authorization more streamlined and consistent. CMS expects prior authorization requests to be processed within 72 hours of being received and is encouraging providers to use electronic submissions to speed up reviews, another official told reporters on Thursday.
Still, some experts raised questions about whether Humana, the program's central administrator, is prepared to handle what could be millions of requests. In a statement to CNBC, Humana said it has 15 years of experience administering a temporary Medicare drug coverage program for low-income beneficiaries and will play a similar operational role in Bridge. CMS, meanwhile, remains responsible for program costs, pharmacy payments, and beneficiary communications, among other efforts.
There is a larger question hanging over the Medicare breakthrough. Unless the Trump administration extends or replaces the demonstration program, obesity drug coverage is scheduled to expire at the end of 2027. Covering the drugs permanently would require a change in federal law or at least agreement among private health insurers to provide the medications in Part D plans. That creates uncertainty for patients who may begin treatments that many experts view as lifelong therapies.
"It's good news that Medicare is rolling out this program, but it is temporary, so it's really not clear at this point what happens after the end of the 18-month program duration," said Juliette Cubanski, director of the Program on Medicare Policy at KFF. "Whether that coverage will continue in some other fashion, or whether people might lose access at that point."
The launch of Bridge could unleash significant pent-up demand for obesity drugs, potentially creating new pressures for physicians, pharmacies, and the prior authorization process, some experts said. That also risks delaying older Americans from getting their hands on the medications.
The new coverage could unlock millions of potential patients for Novo Nordisk and Eli Lilly, intensifying their competition in the obesity market. Lilly currently leads with roughly 60% market share, compared with Novo's 39% as of the first quarter. Neither company has disclosed revenue projections for Bridge. Lilly's Yuffa said uptake will depend on factors including patient and physician awareness and how smoothly the healthcare system handles demand, which will take time to build.
Still, some analysts expect the program to create a meaningful growth opportunity. Leerink Partners analyst David Risinger said he expects volume growth of the companies' obesity drug prescriptions to start picking up in July, with rapid adoption over the second half of the year. He said the program could bring in more than a billion dollars in annual revenue for each company, but expects no major changes in their market share.
Novo Nordisk's and Eli Lilly's oral obesity drugs may be particularly attractive to seniors, Risinger said. The Wegovy pill surpassed 3 million prescriptions in its first five months on the market, while Lilly launched Foundayo in April. Novo Nordisk's market research found that 75% of seniors prefer a daily pill over a weekly injection, according to Jamey Millar, the company's executive vice president of U.S. operations.
Millar described Bridge as a significant opportunity for both companies to compete for a new patient population. He added that if the program demonstrates improved health outcomes and cost savings for Medicare, it could strengthen the case for broader obesity drug coverage across the healthcare system. He said Novo is confident it can sustain the strong uptake of the Wegovy pill as the program launches, touting that the pill has slightly higher efficacy and fewer drug-to-drug interactions compared with Lilly's.
But Millar said the new patient population will be the next opportunity for a jump ball between Novo's and Lilly's medications. "From my perspective, both companies are treating this very intentionally and seriously as an opportunity for access," Millar said. If the program proves that coverage results in cost savings for CMS and improved health outcomes, that could put pressure on more private insurers to provide coverage as well.
Peptides referenced: Semaglutide, Tirzepatide, GLP-1.
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