New Medicare GLP-1 Bridge Program

[Donno]

I haven't seen this discussed anywhere, so I thought I would post a new thread.
Beginning July 1 Medicare is starting a new program that will offer GLP-1 weight loss drugs to those on Medicare that have a plan D drug plan for $50 a month. The caveat is it requires pre-authorization and is dependent on having a BMI of 35 or 30-35 with certain other diagnoses.
Here are a couple of links with the specifics from CMS and also another link to a video that does a good job of explaining it if anyone is interested.

CMS Link
YouTube Video

 

[Koolau]

Darn, I got my BMI to less than 30!! What was I thinking?

 

[EastWest Gal]

I did the same but that was a couple of years ago. I got stuck and was willing to pay for compounded tirzepatide. I'm not sure if it was the medication or the placebo effect of paying so much, but I'm at goal weight and weaning off. A few thousand dollars was a small price to pay for how I feel now, which is terrific.

 

[Flieger]

If Type 2 Diabetic, depending your Part D you may already be covered.

Flieger

 

[folivier]

I would love to lose 30 pounds. But not sure I want to take the risk of bouncing back once I would quit the Rx.

 

[Koolau]

I would love to lose 30 pounds. But not sure I want to take the risk of bouncing back once I would quit the Rx.

I think they have a maintenance dose though it's not cheap. I'd think of it as the "price of good health."

 

[RetiredHappy]

I want to lose another 10 pounds but have BMI of 22 which disqualifies me. I will have to continue to diet.

 

[Koolau]

I want to lose another 10 pounds but have BMI of 22 which disqualifies me. I will have to continue to diet.

At BMI of 22 I guess I would ask "why" you want to lose more weight - but I realize we're all different in how we evaluate how we feel about our weight.

 

[RetiredHappy]

At BMI of 22 I guess I would ask "why" you want to lose more weight - but I realize we're all different in how we evaluate how we feel about our weight.

Blood pressure is still too high while I am on drugs that I can tolerate is the main reason to want to get my weight down. I have also favored a pescatarian diet to help lower my blood pressure.

 

[audreyh1]

Blood pressure is still too high while I am on drugs that I can tolerate is the main reason to want to get my weight down. I have also favored a pescatarian diet to help lower my blood pressure.

I think you eat very low carb, right? That usually helps lower blood pressure significantly plus you already get plenty of exercise. But the body is a complex thing.

 

[RetiredHappy]

I think you eat very low carb, right? That usually helps lower blood pressure significantly plus you already get plenty of exercise. But the body is a complex thing.

Yep, low carbs and golf 5 days a week.

 

[Romer]

Reading the criteria Medicare GLP-1 Bridge | CMS

The beneficiary is prescribed the requested drug to reduce excess body weight and maintain weight reduction in combination with current and ongoing lifestyle modification including structured nutrition and physical activity consistent with the applicable FDA approved label, AND

• The beneficiary is at least eighteen (18) years of age and has a BMI greater than or equal to thirty-five (≥35) at the time of initiation of GLP-1 therapy, or
• The beneficiary is at least eighteen (18) years of age and has a BMI greater than or equal to thirty (≥30) at the time of initiating GLP-1 therapy with a diagnosis of one or more of the following: (A) heart failure with preserved ejection fraction, (B) uncontrolled hypertension (defined as systolic blood pressure above 140 mm Hg or diastolic blood pressure above 90 mm Hg, despite concurrent treatment with two antihypertensive medications), or (C) chronic kidney disease stage 3a or above, or

So if your BMI was over 30 and you had High Blood Pressure when you initiated taking the drug, will it cover you even if your now around 25 BMI and no longer have High Blood Pressure and still taking it?

I think it says yes?