Medicare and Weight Loss: Counseling, the GLP-1 Bridge and Part D

Liam: The reason you take it matters. These are often called G L P one medicines. That group includes Wegovy and Zepbound. Part D can still cover them for other approved uses.

Claire: Thanks for joining us. You're listening to Between Visits, sponsored by Hope Health Network, a network of medical practices serving South Carolina. We dig into the medical and mental health topics that matter most to patients and the public.

Claire: I'm Claire, and this is episode 8. I'm going to quickly play our disclaimers, and then we'll get started!

Recorded disclaimer: This show is for entertainment, education and general information only. It's not medical advice, and listening doesn't make you a patient. Our hosts and guests are not real people, medical doctors or healthcare providers. We do our best, but we can be wrong, and our content can have errors and omissions. Talk with a licensed medical provider in your state before you make any decisions about your health or medical care.

Claire: In an emergency, call 911. In a crisis, call or text 988.

Claire: Joining me today is Liam, from our digital entertainment team. Welcome, Liam!

Liam: Glad to be back, Claire. I've been looking forward to this one.

Claire: Me too. People keep asking about this, so it's good timing.

Liam: Then let's not keep them waiting.

Claire: Today we're talking about Medicare and Weight Loss: Counseling, the GLP-1 Bridge and Part D. Well, we're excited to get your thoughts on this important topic, Liam. Let's get started.

Claire: Today we're talking about Medicare and weight loss. If you have Medicare and you want help with your weight, it can be really hard to tell what's covered.

Liam: It can. But you may have more options than you think. Medicare covers weight-loss counseling in primary care for people who qualify. And a temporary program now offers certain weight-loss medicines to some people with Medicare drug coverage.

Claire: So there's counseling, there's your drug plan, and there's this new program. Three pieces.

Liam: Right. And one note up front. Today we're talking about Medicare's rules. If you have another kind of insurance, check with your own plan.

Claire: Fair enough. Let's start with counseling. Who gets that?

Liam: Medicare Part B covers it. Medicare dot gov calls it obesity behavioral therapy. In plain words, that's counseling on diet and exercise for weight loss.

Claire: Medicare does love its letters and long names. So who qualifies?

Liam: It really does. You must have a body mass index of 30 or more. You'll hear that called B M I. It's your weight relative to your height.

Claire: And what do you actually get?

Liam: You get a B M I screening, a dietary assessment, which is a look at how you eat, and the counseling itself.

Claire: Can I see just anyone for that?

Liam: No. You must get it from your primary care doctor or another primary care provider. And it has to be in a primary care setting, like a doctor's office.

Claire: How often do you go? Is this a once-a-year thing?

Liam: It's more often than that. Medicare's rules set the schedule. One face-to-face visit every week for the first month. Then one visit every other week in months 2 to 6.

Claire: So every week, then every two weeks. And after six months?

Liam: One visit a month in months 7 to 12. But only if you've lost at least 3 kilograms in the first 6 months. That's about 6.6 pounds.

Claire: So what if someone tries hard and doesn't get there? That feels a little tough.

Liam: It can feel that way. If you haven't lost 3 kilograms by the six-month visit, the monthly visits do not continue. Your B M I and your readiness to change are checked again after another 6 months.

Claire: So someone takes another look after six more months.

Liam: Right.

Claire: And what does all of this cost?

Liam: Medicare dot gov says you pay nothing for this counseling if your provider accepts assignment. That means your provider accepts the Medicare-approved amount as full payment.

Claire: So nothing, as long as your provider accepts that amount.

Liam: Yes, for the counseling. If your provider recommends other services, ask whether Medicare covers them. Those can cost you money.

Claire: Good tip. Okay, now the question a lot of people have. What about the medicines? Will my Part D plan pay for one of those weight-loss shots?

Liam: Part D means Medicare drug plans. And those plans do not cover drugs when they are used for weight loss.

Claire: Oh. So that's a no.

Liam: For weight loss, yes, that's a no. The Centers for Medicare and Medicaid Services is the federal agency that runs Medicare. It excludes those drugs from Part D when they're used for weight loss.

Claire: But I know people on Medicare who take these medicines. How does that work?

Liam: The reason you take it matters. These are often called G L P one medicines. That group includes Wegovy and Zepbound. Part D can still cover them for other approved uses.

Claire: Other uses like what?

Liam: In a June 2026 memo, the agency told Part D plans they must keep covering these drugs for uses Part D already covers. One example is Zepbound for moderate to severe obstructive sleep apnea in adults with obesity.

Claire: So sleep apnea. What else?

Liam: Another example is Wegovy, to lower the risk of major heart problems in adults with established heart disease and either obesity or overweight. The agency also lists type 2 diabetes. And it lists MASH with moderate to advanced liver scarring. MASH is a type of fatty liver disease.

Claire: So it could be the same kind of drug, but the reason you're taking it changes the answer.

Liam: Exactly. That's the part that trips people up.

Claire: Okay. So what is this Bridge program I keep hearing about?

Liam: The Medicare G L P one Bridge is a short-term program run by that same agency. It covers certain of these drugs for weight management, from July 1, 2026, through December 31, 2027.

Claire: So it's temporary. Do I sign up for it instead of my drug plan?

Liam: Not quite. It runs outside your Part D plan, but you need Part D coverage to use it. That can be a stand-alone drug plan, or most Medicare Advantage plans with drug coverage.

Claire: Okay. And who qualifies? I'm guessing it's not everybody.

Liam: Right. You must be 18 or older. And when you start the medicine, you must fit one of three groups. The first group is simple. A B M I of 35 or more.

Claire: And the second group?

Liam: A B M I of 30 or more, plus one of three health problems. One is high blood pressure that stays above 140 over 90 despite two blood pressure medicines.

Claire: What are the other two?

Liam: Chronic kidney disease stage 3 a or higher, which means at least a mild to moderate loss of kidney function. Or heart failure with preserved ejection fraction. That's a type of heart failure where the heart muscle is stiff and doesn't fill with blood easily, even though it pumps normally.

Claire: That's a mouthful. Your provider can sort that one out with you, I hope. And the third group?

Liam: They can talk it through with you. The third group is a B M I of 27 or more, plus prediabetes, a past heart attack or stroke, or peripheral artery disease with symptoms.

Claire: Is there anyone who can't use it, even if their numbers fit?

Liam: Yes. You are not eligible if you have type 2 diabetes, moderate to severe sleep apnea or MASH. You're also not eligible if you've already received one of these drugs through your Part D plan.

Claire: So some of the people who can't use the Bridge may have a path through Part D.

Liam: That's right. Those conditions are on the list of Part D uses we just talked about. Your provider can help you sort out which path may fit.

Claire: Which drugs does the Bridge cover?

Liam: Foundayo tablets, Wegovy injection or tablets, and the Zepbound KwikPen. The single-dose Zepbound pen and Zepbound vials are not covered.

Claire: Oh, so even the form of the drug matters. Good to know. What does my provider have to do?

Liam: Two things. Your provider must certify that you're using the medicine as part of a lifestyle program focused on diet and exercise. And your provider must complete a prior authorization, which is an approval step.

Claire: And who has the final word on whether I qualify?

Liam: The federal agency confirms who is eligible for the Bridge.

Claire: Now the money part. What would I pay?

Liam: If you qualify, you pay a 50 dollar copayment for a one-month supply. The agency says it stays at 50 dollars in every phase of Part D coverage.

Claire: So 50 dollars a month, and it doesn't jump around. Does that 50 dollars count toward my deductible?

Liam: No. It does not count toward your Part D deductible or your out-of-pocket limit. And Extra Help cannot lower it.

Claire: So those 50 dollars don't get me any closer to those limits. And if I have questions, who do I call?

Liam: For questions about the Bridge, you can call 1-800-MEDICARE.

Claire: This is also the time of year people are looking at their plans, right?

Liam: Yes. Medicare Open Enrollment runs from October 15 to December 7. Changes you make during that time take effect January 1.

Claire: What should someone look for if they're choosing a plan?

Liam: Medicare Advantage plans must cover all the services Original Medicare covers. But many use networks, and out-of-network care usually costs more. So if you're choosing a plan for 2027, check that the providers you want to see are in its network.

Claire: So check before you switch, not after. And if someone's still not sure where they fit, what could they ask at their next visit?

Liam: Here's a simple one. Which path fits me: counseling visits, my Part D plan or the G L P one Bridge?

Claire: I like that. It's short, and you could write it on your hand.

Liam: You could. A sticky note works too.

Claire: Okay, before we wrap up. If people only remember a few things from today, what should they be?

Liam: First, if your B M I is 30 or more, Part B covers weight-loss counseling with a primary care provider. Ask whether your provider accepts assignment.

Claire: Okay. What else?

Liam: Second, Part D doesn't cover these drugs when they're used for weight loss. But it can still cover them for other approved uses, like type 2 diabetes.

Claire: And one more?

Liam: The Bridge is temporary and it's set to end December 31, 2027. It has its own rules and a 50 dollar monthly copay, so ask your provider whether you may qualify.

Claire: That's really helpful. Thank you for walking us through this.

Liam: Thanks for having me, Claire. I hope it helps someone.

Claire: This episode is sponsored by Hope Health Network. Its member practices all have providers experienced in weight-loss counseling, or can refer you to a network provider who is. Hope Health Network medical practices provide evidence-based medical care and include Hope Integrative Medicine, Hope Medical Associates, Hope Behavioral Medicine and Hope Addiction Medicine. To learn more, go to Hope Health Network dot com. That website, along with appointment links for all four practices, is in the description of this episode.

Claire: One last reminder. In an emergency, call 911. In a crisis, call or text 988.

Claire: This podcast is a production of Hope Health Network Media.

Claire: You've been listening to episode 8 of Between Visits, Medicare and Weight Loss: Counseling, the GLP-1 Bridge and Part D. Thanks for hanging out with us. See you next time!