And this page has the criteria for the Medicare BRIDGE program (the one that’s from July 2026-December 2026 for Medicare). Very similar but slight differences.
It’s under the FAQ - Medicare GLP-1 Bridge Eligibility and Participation
Q: What clinical criteria must a beneficiary meet in order to qualify for the Medicare GLP-1 Bridge?
There are patients like me who do not respond at all to semaglutide; minimally to tirzepatide, and pin our hopes on retatrutide or other future GL-type drugs. What is the insurance landscape looking like for us?
As one who will be directly impacted by this as soon as it's available (just hit my Medicare era in January), I'm cautiously optimistic for myself ... and for all of us. (Because I know: Medicare goes first, and private insurance usually follows.)
And yet, I'm still a bit confused about whether or not I - and many of my friends already in treatment - will qualify for this program. I read (can't remember where now, but do remember it was a legit article from a trusted news source...) that if a patient has a BMI lower than 27, they won't qualify at all. This same article said there were no provisions for continuation of care. Then, on the BRIDGE page of CMS.gov it says that the BMI has to be 35 with comorbidities at the time of "initiating GLP1 therapy" or 27 with other (seemingly more serious) comorbidities. That would indicate that the BMI measurement could have come months or years prior - before treatment. But what if there were none of these comorbidities they list? (I didn't have any of them...)
Will I qualify, or won't I? The overall program is encouraging, but I have a feeling I'm not going to qualify ... bummer.
Any chance you and your magic ability to sift through all this seemingly disparate info can clarify?
Will those of us who have experienced success on Zepbound still qualify for continuing coverage? Currently BMI below criteria listed but only with the help of ongoing use of Zepbound.
I don't know how you make sense of this info..it all sounds very confusing but thanks, as always, for your reporting to us all.
On this page, under FAQ: Who is eligible to receive GLP-1 medications under BALANCE, it has the clinical criteria - which includes PRE-DIABETES. Woah.
https://www.cms.gov/priorities/innovation/innovation-models/balance
And this page has the criteria for the Medicare BRIDGE program (the one that’s from July 2026-December 2026 for Medicare). Very similar but slight differences.
It’s under the FAQ - Medicare GLP-1 Bridge Eligibility and Participation
Q: What clinical criteria must a beneficiary meet in order to qualify for the Medicare GLP-1 Bridge?
https://www.cms.gov/medicare/coverage/prescription-drug-coverage/medicare-glp-1-bridge
Thank you for always keeping the community updated and informed.
We have to get TROA passed!
There are patients like me who do not respond at all to semaglutide; minimally to tirzepatide, and pin our hopes on retatrutide or other future GL-type drugs. What is the insurance landscape looking like for us?
As one who will be directly impacted by this as soon as it's available (just hit my Medicare era in January), I'm cautiously optimistic for myself ... and for all of us. (Because I know: Medicare goes first, and private insurance usually follows.)
And yet, I'm still a bit confused about whether or not I - and many of my friends already in treatment - will qualify for this program. I read (can't remember where now, but do remember it was a legit article from a trusted news source...) that if a patient has a BMI lower than 27, they won't qualify at all. This same article said there were no provisions for continuation of care. Then, on the BRIDGE page of CMS.gov it says that the BMI has to be 35 with comorbidities at the time of "initiating GLP1 therapy" or 27 with other (seemingly more serious) comorbidities. That would indicate that the BMI measurement could have come months or years prior - before treatment. But what if there were none of these comorbidities they list? (I didn't have any of them...)
Will I qualify, or won't I? The overall program is encouraging, but I have a feeling I'm not going to qualify ... bummer.
Any chance you and your magic ability to sift through all this seemingly disparate info can clarify?
Will those of us who have experienced success on Zepbound still qualify for continuing coverage? Currently BMI below criteria listed but only with the help of ongoing use of Zepbound.
Any idea where AARP stands on this?