Some people covered by Medicare or Medicare Advantage now qualify for GLP-1 weight loss drugs at a lower price – $50 a month. To help people figure out who qualifies, what is involved and what to expect for first-time GLP-1 users, a pair of weight management specialists at MUSC Health sat down for this Q&A.
Josh Neal, M.D., is an obesity medicine physician at MUSC Health. Nicole Martinez de Andino, a nurse practitioner and registered dietitian, directs clinical operations for the MUSC Weight Management Center.
Who qualifies for GLP-1 coverage under the new plan?
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Neal: So, this is people with Medicare Part D. Most Medicare Advantage plans have a Medicare Part D coverage. Part D is the drug coverage component of Medicare. Then, they need to meet certain BMI (body mass index) criteria, and there are some exclusion criteria.
What are the exclusion criteria?
Neal: If you already have coverage or qualify for GLP-1 for another indication, whether that is diabetes, moderate to severe sleep apnea, metabolic dysfunction-associated steatotic liver disease, which used to be called fatty liver disease.
Those indications are exclusions, and they would go through our normal Medicare Part D coverage, even if your insurance does not give coverage for those things or even if your insurance makes it cost more than this program, which is a $50 per month payment.
What are the inclusion criteria?
Neal: If you have Part D coverage without exclusionary factors, we would look at your BMI. Anybody who has a BMI over 35 should qualify for this program.
If you do not have a BMI over 35 but have a BMI over 30 and either have heart failure with preserved ejection fraction, chronic kidney disease stage three A or above, uncontrolled high blood pressure on two or more anti-hypertensive agents, then you qualify.
And then if you have a BMI of 27 or above and have either pre-diabetes, a prior heart attack, a prior stroke or significant peripheral arterial disease, you will also qualify.
How do GLP-1 medications work?
Martinez de Andino: GLP-1 medications slow the rate at which food leaves the stomach, so GLP-1 users stay full longer and do not feel as hungry. These medications also impact hunger hormones, so people taking them do not think about food as much, which makes it easier to make healthier food choices.
What about side effects?
Martinez de Andino: Because these medications work by slowing stomach emptying, most of the side effects are GI [gastrointestinal] related. Delayed stomach emptying can cause nausea, vomiting, constipation or heartburn, especially when starting the medication or increasing the dose. Those are the main side effects. How people eat when taking these medications matters. Smaller meals, slower eating and stopping when full can reduce side effects.
How much weight can people lose?
Martinez de Andino: It depends on the medication; in the clinical trials, people lost around 15 to 20% of their total body weight.
Neal: In real life, people are not meeting with a dietician every couple of weeks or having counseling that is quite as intensive. So, in real life, it looks like about half that as much weight loss.
Lifestyle components are critical to having ongoing success. So, nutrition, physical activity, dietary modifications, those are important for people to find success. Our Health and Wellness Institute is coming up with a digital health coaching platform to help people track their metrics both with physical activity and nutrition.
Is the new health coaching platform for people on GLP-1s specifically?
Neal: No, it is a health coaching platform that includes all lifestyle modifications.
How have GLP-1s affected the MUSC Weight Management Center’s approach?
Martinez de Andino: As more people use GLP-1 medications for weight management, we have created programs specifically designed to support their unique needs and help them be successful long term.
We offer virtual group classes with our dieticians, exercise physiologists and behavioral specialists. These experts help patients with weight management medications maintain a healthy diet, meet their protein needs and reduce the risk of vitamin and mineral deficiencies. They also provide guidance on incorporating strength training to help preserve muscle mass during weight loss, as well as help patients develop healthy habits, set goals, stay motivated, overcome challenges and create lasting behavior changes that support weight management and overall health.
GLP-1 medications may not be the right tool for everyone trying to lose weight. The MUSC Health Weight Management Center provides a variety of evidence-based programs designed to support people on their weight loss journey, regardless of whether weight loss medications are part of their treatment plan. We offer structured lifestyle programs, nutrition counseling, behavioral support, exercise guidance and group classes.
Are GLP-1 weight loss drugs shots or pills?
Neal: Both. There are two covered injections. One is Wegovy, goes by the generic name semaglutide. The other is Zepbound, which is also known as tirzepatide.
But the Wegovy pill is also covered, along with Foundayo, which is orforglipron. And that one, Foundayo, is not a peptide, but a small molecule that also hits the GLP-1 receptor.
There is a little bit more weight loss associated with the injections than the oral versions, but they are all going to be available for $50 through this program.
What does it mean that this is a temporary bridge program?
Neal: It got put in place as a temporary measure from Congress to try to bridge their way to another program called BALANCE. [BALANCE, better approaches to lifestyle and nutrition for comprehensive health, is intended to lower prices by having the Centers for Medicare and Medicaid Services negotiating pricing directly with drug-makers.]
Medicare GLP-1 Bridge runs from July 1st, 2026, all the way through December 31st, 2027. So the hope is that Congress will pass legislation for the BALANCE program by that point. These medications can be really impactful and life altering for a lot of my patients. I think that it would be very unpopular once you have patients on these medicines to try to take that away.
