Medicare’s New GLP-1 Weight Loss Pilot Program
“This is a new test program, and it’s a genuinely exciting one for Medicare beneficiaries. If you think you might qualify, now is the time to find out.” ~ Susan Booth, Operations Director at Ark Insurance Solutions
If you’ve been thinking about exploring weight management with a GLP-1, but unable to afford it due to limited coverage, we’ve got exciting news for you. Medicare just made a big change in how it covers weight loss medications, with an update on July 1 that launched a brand new pilot program. Eligible beneficiaries now have access to certain GLP-1 medications for weight management at a flat $50 copay, and the program is scheduled to run through December 2027.
If you’re on Medicare and considering GLP-1 medications, here’s what you need to know about how the program works, who qualifies, and what to do next.
How Does This Program Work?
Medicare’s pilot program gives eligible beneficiaries temporary access to select GLP-1 medications outside of what their Part D plan would normally cover. It’s run through Medicare, and to participate, you need to already have a Part D prescription drug plan, whether that’s a standalone plan or bundled into a Medicare Advantage plan.
This is a test model, so the rules and processes are still new. But if you meet the eligibility requirements and get prior authorization from your doctor, your qualifying GLP-1 medication could be available for a $50 monthly copay.
Who Qualifies?
Eligibility is based on body mass index (BMI) and, for some beneficiaries, certain related health conditions. An important aspect of this program is that it’s specifically geared toward weight loss, not diabetes management. A diabetes diagnosis alone doesn’t determine eligibility, and medications prescribed primarily for diabetes (like Ozempic) aren’t part of this particular pilot.
Which Medications are Covered?
Three GLP-1 medications are currently approved under the pilot: Wegovy (available as an injection or tablet), Zepbound (available as an auto-injector pen), and Foundayo, an oral tablet option. Beneficiaries who qualify and receive prior authorization can access any of these medications under this new program.
How to Get Started
The process for this program works much like any other prior authorization for a prescription medication:
- Talk to your primary care doctor about whether you meet BMI and health condition requirements.
- Your doctor submits a prior authorization request to your Part D carrier, documenting why you qualify.
- Once approved, you can access one of the qualifying medications at the $50 copay.
If you don’t currently have a Part D plan, or you’re not sure whether your plan’s formulary includes these medications, we can help you find out. Our team can review your plan and help make sure it lines up with the medications you’re taking or hoping to take.
Already Taking a GLP-1?
If you’re already taking a qualifying GLP-1 and paying out of pocket, and your doctor has already documented your need for it, this pilot may lower your monthly cost significantly.
The details of that transition are still being worked out since the program is so new, but if you’re in this situation, it’s worth having a conversation with your doctor and your Part D carrier to confirm your next steps.
Mark Your Calendar for Annual Enrollment
Heads up: Medicare’s Annual Enrollment Period is around the corner, running from October 15 through December 7. It’s the best time to check in with your plan and make sure it still fits your needs. If you don’t currently have a Part D plan, this window is the best time to add one.
And if you already have a Part D plan, it’s also worth taking a look at all of your current medications and verifying that you’re getting the lowest price available to you.
This new GLP-1 pilot program is a big shift for Medicare beneficiaries who’ve wanted access to these medications for weight management, but haven’t been able to find an affordable way to get started.
If you have questions about how your Medicare plan works, or you’d like to make sure your plan covers the medications you need, we’re here to help. Give us a call at 801-901-7800 or click here to schedule an appointment with us.
