Medicare will start covering weight-loss drugs on July 1 for the first time. Here’s what you need to know

(CNN) — Millions of Medicare enrollees will gain their first-ever coverage for drugs for weight loss under a temporary pilot program that launches July 1.

Mary Abrahamson hopes to be one of them.

The rural Washington resident was tired of carrying extra weight on her 5-foot-3-inch frame. It made it harder for the 71-year-old to do the things she enjoyed, including walking her dogs and gardening.

Unable to afford the weight-loss drugs Wegovy or Zepbound, which were priced at more than $1,000 a month at the time, Abrahamson started using a compounded version of the GLP-1 drug tirzepatide two years ago, which initially cost her $400 a month but has since dropped to $200. Her husband, Jeff, 77, began earlier this year. Both have shed pounds and have more energy – though the monthly tab is a struggle financially.

The couple, who live off of Social Security, savings and a small pension, may soon be able to get Zepbound for $50 a month each through the Medicare pilot program. The steep discount would allow them to buy a new riding lawn mower or improve their drinking water system or take a dream vacation to Belize, where Abramhamson has already picked out a resort.

“With this weight loss, I feel 10 years younger,” said Abrahamson, who no longer struggles with sleep apnea and other ailments since starting the compounded GLP-1. “It changed my life for the better. I don’t want to give it up.”

The Abrahamsons are hoping to be among the millions of senior citizens who will become eligible to obtain weight loss drugs through Medicare for the first time in the program’s history. It is launching the temporary pilot, called Medicare GLP-1 Bridge, on July 1.

Medicare is prohibited by law from covering weight-loss drugs, but the Centers for Medicare and Medicaid Services is allowed to run short-term demonstration projects to test new payment and coverage models. The Bridge effort is part of a deal that the Trump administration announced in November with drugmakers Eli Lilly and Novo Nordisk to reduce the cost of their blockbuster anti-obesity medications.

Doctors and patient advocates have been clamoring for years to expand Medicare coverage to weight-loss drugs, arguing that obesity should be treated like any disease. The cost of buying GLP-1 medications without insurance can still run into hundreds of dollars.

Dr. Catherine Varney, obesity medicine director at the University of Virginia, has about 100 Medicare patients who will probably be eligible for Bridge program. None of them can afford to pay for weight-loss medications out of pocket, she said. Several have told her they are relieved that they may finally be able to obtain the drugs at a reasonable price.

“Most of these patients that I wanted to start on this medication are ticking time bombs,” said Varney, who is also a trustee of the Obesity Medicine Association. “They’ve got prediabetes, high blood pressure, high cholesterol, all these cardiac risk factors that are leading to heart attack and stroke.”

For many enrollees, the pilot program is more than just a chance to get weight-loss drugs at a discount, said Patty Nece, past chair of the Obesity Action Coalition, a patient advocacy group with nearly 100,000 members in the US.

“A lot of it is about acknowledgement that their disease should be treated like any other disease and essentially have coverage for the medications without outrageous copays,” Nece told CNN.

Here’s what we know about the Bridge program.

Who is eligible?

Only certain Medicare enrollees are eligible. Not only must they be enrolled in a Part D drug coverage plan, they have to meet specific health criteria when they started taking GLP-1 medications, even if it preceded the launch of the Bridge program.

Those with a body mass index, or BMI, of 35 or more qualify. Those with a BMI between 30 and 35 must also have one of the following: uncontrolled high blood pressure, prediabetes, a previous heart attack or stroke, blocked arteries in arms or legs with symptoms, chronic kidney disease at Stage 3a or higher, or diastolic heart failure.

Those with a BMI between 27 and 30 must also have either prediabetes, a previous heart attack or stroke, or blocked arteries in arms or legs with symptoms.

Enrollees are not eligible if they already receive GLP-1 medications through their Medicare Part D drug plan or have type 2 diabetes, moderate to severe sleep apnea or fatty liver disease (which might make them eligible for coverage through Part D).

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

Many Medicare enrollees are uncertain whether they are even eligible for the program. Deb Cooperman, 65, lives in western New Jersey and has been paying $450 a month for Zepbound for just over a year. She’s unsure whether she will meet the BMI qualification; it depends on what height her doctor reports, because she says she has lost an inch since she started going to the practice a decade ago.

Saving $400 a month would be meaningful since she and her husband are getting ready to retire from their careers as a creative writing workshop leader and a psychologist, respectively. Setting aside the funds for Zepbound, which has allowed her to shed 30% of her body weight and given her more energy and less pain, is a top priority, even if that means cutting back on other activities she enjoys.

“Do I want to see a play, or do I want to have this medication that has regulated something that has tortured me since I was a teenager?” Cooperman said. “I want to take the medication. I can skip the play.”

Some Medicare enrollees are disappointed that they do not meet the criteria and can’t access the reduced price.

Diane Lane-Cormier is one of them. When she first heard about the Bridge program, she was very excited

“Maybe I can finally get on something that’s affordable and sustainable,” Lane-Cormier, 68, told CNN.

But that joy was replaced with frustration when she learned she probably won’t qualify because she was prescribed Zepbound last year for sleep apnea — even though she didn’t fill the prescription because the $300 monthly tab was too much for her.

Lane-Cormier, who has lost about 12 pounds over the past two years through diet and exercise, would like to lose up to 30 more pounds, which she said would help her deal with pain, inflammation and other ailments, as well as improve her quality of life.

“I have to just keep working on trying to lose the weight myself,” said the retired nurse who lives in Piedmont, South Carolina.

What medications can beneficiaries receive, and how?

The pilot program covers Wegovy tablets and injections, Zepbound KwikPens and Foundayo tablets. It does not cover single-dose Zepbound vials or pens.

Both Novo Nordisk, which makes Wegovy, and Eli Lilly, which makes Zepbound and Foundayo, say they have enough supply to meet the new demand.

Novo Nordisk is stressing the overall health benefits of Wegovy, including lower risk of cardiovascular problems such as heart attacks and strokes.

“Seniors should be very motivated to get the near-term immediate weight loss benefit, but without having to sacrifice any long-term outcomes in terms of cardiovascular health,” said Jamey Millar, the company’s executive vice president for US operations.

The medications can be obtained through pharmacies. Eligible enrollees interested in Zepbound and Foundayo can also go to LillyDirect Pharmacy, the drugmaker’s direct-to-consumer website.

“For many, this will be the first time obesity treatment has been within reach,” Ilya Yuffa, president of Lilly USA and Global Customer Capabilities, said in a statement.

How much will enrollees have to pay?

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

This is a steep discount compared with the drugs’ cash-pay prices, which run between $149 and $449 per month, depending on the medication and dosage. Still, even $50 a month can be too expensive for some senior citizens living on fixed incomes, said Juliette Cubanski, director of the Program on Medicare Policy at KFF, a health policy research group.

Those with limited incomes who qualify for Medicare’s Extra Help program will still have to pay the $50 charge.

And beneficiaries who already receive GLP-1 drugs for diabetes or other approved conditions through their Part D plans are not eligible to participate in the Bridge program.

How many people will sign up, and how much will the pilot program cost taxpayers?

That’s a big unknown. CMS is not revealing either its cost projection or its enrollment estimate.

However, a high-ranking CMS official said last week that he expects that the number of Medicare beneficiaries who will participate with be in single-digit millions initially.

“But we’ll see where it scales over time,” Chris Klomp, CMS’s Medicare director, who has been nominated for deputy secretary of the US Department of Health and Human Services, said at an Aspen Institute event.

As for the financial impact on Medicare, Klomp said CMS believes that the effort will be cost-neutral over a 24-month period. Adding in a reduction of total cost of care because beneficiaries will be healthier, Klomp said, providing weight loss drugs will be “a material cost-saver.”

Under the Trump administration’s agreement, Eli Lilly and Novo Nordisk will sell the drugs to Medicare for $245 for a month’s supply.

Various prior estimates of how many Medicare enrollees might be considered overweight or obese and how much expanding coverage to weight loss drugs would cost don’t take into account the Bridge program’s eligibility requirements.

Close to 14 million beneficiaries were diagnosed as being overweight or obese in 2020, according to a KFF analysis.

Meanwhile, the Congressional Budget Office previously estimated that 12.5 million enrollees would qualify in 2026 if Medicare were authorized to cover anti-obesity medications. But it expected that only 300,000 would actually start using the drugs that year – though that figure would grow to 1.6 million in 2034.

Expanding coverage would cost the federal government $35 billion between 2026 and 2034, the CBO projected. But the total savings from enrollees’ improved health would be small, it said.

A Biden administration proposal to allow Medicare estimated that 3.4 million Medicare enrollees would gain access at a total cost of $25 billion over a decade.

Doctors interviewed by CNN said they expect a sizeable share of their eligible Medicare patients to seek to join the Bridge program.

“The biggest shift is that the conversation changes from ‘I can’t afford treatment’ to ‘Let’s talk about what treatment is right for you,’ ” said Dr. Katherine Saunders, who is on voluntary faculty at Weill Cornell Medicine and co-founder of FlyteHealth, which focuses on obesity treatment.

But, she said, many patients are still confused and concerned about eligibility and affordability, as well as whether coverage will continue after the Bridge program lapses at the end of next year and whether they can access healthcare professionals for ongoing care and monitoring.

Dr. Jorge Moreno, an obesity specialist at Yale Medicine, is already getting messages from his patients asking about the Bridge program, including some who had been denied coverage in the past.

They are being told to book telehealth appointments after July 1 to discuss the program, though Moreno warns that it may take a little time before they have the drugs in hand.

“As the program rolls out, we’ll get the medications to the patients as we can,” he said, noting that his calendar is already “pretty booked.”

How long does the coverage last?

The Bridge program will run through the end of 2027. It was originally designed as a six-month effort, after which time Medicare Part D insurers would start providing coverage under a pilot program called the Balance model at the start of next year.

Insurer participation in Balance, however, is voluntary. Not enough Part D plans signed up, which prompted CMS to extend the Bridge program to 18 months. The agency is collecting data for a potential launch of the Balance program in the future.

Insurers were reluctant to participate because they didn’t have a sense of how much it would cost them to cover weight loss drugs for eligible Medicare enrollees, Cubanski said. They may not have been able to absorb the additional expense without having to raise premiums for everyone.

It’s not clear that insurers will want to sign up for the Balance model for 2028, even after they see how much demand there is under the Bridge program, said Brian Reid, principal of Reid Strategic, a consulting firm on pharmaceutical issues.

“There will either have to be a big carrot or a big stick to get the insurers to participate,” Reid said.

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