On November 6, President Donald Trump announced the GENErating cost Reductions fOr U.S. Medicaid (GENEROUS) model with pharmaceutical companies Eli Lilly and Novo Nordisk.
The model extends GLP-1 coverage to Medicare and Medicaid beneficiaries. This is great news for your clients interested in weight loss drugs!
Without insurance coverage for GLP-1 medications, known by brand names Fundayo, Ozempic, Wegovy, Mounjaro, or Zepbound, individuals could spend anywhere from $900 to $1,300 a month. Previously, this group included Medicare beneficiaries without type 2 diabetes.
GLP-1 Medicare and Medicaid coverage will begin in 2026 through a pilot program called the GLP-1 bridge. Here’s what you need to know to answer client questions around weight loss drugs covered by Medicare and Medicaid.
What GLP-1 Medications Could Be Covered?
The Medicare GLP-1 Bridge program will cover three prescription weight loss medications:
- Fundayo
- Wegovy injection or tablet
- Zepbound Kwikpen (single-dose pens and vials are not covered)
Medicare and Medicaid will not cover other GLP-1s for weight loss.
When Will Savings Begin for Beneficiaries?
In January, the Trump administration debuted TrumpRx.gov where consumers can purchase the medications at a discount if they are not eligible to participate in the GLP-1 bridge program. We discussed whether TrumpRx and other drug discount programs could be best for your clients.
For consumers obtaining a GLP-1 through their Medicare coverage, these savings will begin July 1, 2026.
The GLP-1 bridge program will end December 31, 2027. The BALANCE program is currently set to begin in 2028. Details surrounding Medicaid coverage are varied due to the opt-in nature of the program.
Savings for Medicare Clients
The GENEROUS model extends Medicare coverage to beneficiaries with obesity. Previously, only those with type 2 diabetes or cardiovascular disease could receive coverage for GLP-1 medications. It’s estimated that this expanded coverage may cover 10 percent of Medicare beneficiaries.
Expanded coverage of GLP-1 medications may cover 10 percent of Medicare beneficiaries.
Beneficiaries with Part D benefits can qualify for discounted GLP-1 coverage by meeting one of the following requirements:
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Group 1: Overweight individuals with a Body Mass Index (BMI) greater than 27, individuals with prediabetes or have had a heart attack, stroke or blocked arteries in your legs or arms
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Group 2: Overweight individuals with a BMI greater than 30, individuals with certain types of heart failure, high blood pressure that’s hard to control, or chronic kidney disease (stage 3a or above)
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Group 3: Overweight individuals with a BMI greater than 35.
Note: Medicare beneficiaries wishing to receive a GLP-1 for weight loss alone without a related risk factor will not be eligible for savings under the GLP-1 bridge. If a beneficiary has type 2 diabetes, moderate-to-severe sleep apnea, or fibrosis, their plan may already cover a GLP-1 drug for them.
Savings for Medicaid Beneficiaries
To mitigate risks associated with lifelong obesity, the Trump administration also wishes to extend coverage to Medicaid. Through the Medicaid GLP-1 bridge, state Medicaid programs will have to opt in to provide lower-priced GLP-1 medications to eligible individuals.
As the program stands, states will have to issue a letter of intent before July 31, and then they will be invited to participate in the pricing agreement later. Through this agreement, specific costs and who is able to receive the medication will be negotiated.
States may choose their own start date between May 1, 2027, and January 1, 2027, after being accepted to the BALANCE program. States that do not join before January 1, 2027, will only be allowed to participate at the discretion of CMS. At this time, it’s not yet clear which states plan to participate.
Due to the “opt-in” nature of this program, it’s difficult to estimate how many Medicaid beneficiaries could access lower pricing for these medications.
What Will a GLP-1 Medication Cost?
Starting doses of Wegovy and Zepbound will cost the Medicare and Medicaid programs $350 a month and decrease in cost over a two-year period.
The lowest doses of drugs used to treat type 2 diabetes, Ozempic and Mounjaro, will cost the programs $245 a month and decrease in cost over two years as well.
A Medicare beneficiary who qualifies for coverage under the expanded criteria or the Part D phase-in plan will pay only $50 a month for a covered GLP-1 medication. This is a notable savings from what beneficiaries are spending on GLP-1s today.
Why This Program Is Critical for Americans’ Health
GLP-1 medications are a valuable treatment for those with type 2 diabetes, lowering blood sugars and with continued use, A1C levels as well. The treatment of type 2 diabetes with GLP-1s has been a proven method since 2005. It was discovered that weight loss was also associated with these drugs, and through developing more GLP-1 medications in the last several years, their popularity has grown.
The GLP-1 bridge is the first significant stride toward more affordable GLP-1 coverage for a wider group of individuals.
It’s difficult for many to access these medications due to the costs without insurance, and many prescribers also require prior authorization from a doctor. The GLP-1 bridge is the first significant stride toward more affordable GLP-1 coverage for a wider group of individuals.
Obesity increases the risk for death anywhere from 22 to 91 percent, according to research from University of Colorado Boulder. Providing access to proven GLP-1 medications could benefit health outcomes for a wide group of Americans and reduce the strain on the healthcare system associated with treating diabetes and related conditions.
How to Notify Clients of This Update
For your clients with a Part D plan that could qualify for GLP-1 coverage as part of the GLP-1 bridge, let them know to speak to their doctor about these treatments if they are interested. Use this guide to educate beneficiaries about the program and how they could benefit.
It’s also possible that many of your clients could already take these medications. Let them know that they could be paying less for them. We will keep agents informed about the changes that come with this pricing model.
President Trump’s GENEROUS model and GLP-1 bridge could make major strides for making GLP-1 medications more affordable for many. Treating diabetes and obesity to improve health outcomes for Americans has become a priority for this administration.
Register with Ritter today for free to have access to online contracting through Contract Now with carriers that offer Part D coverage that could participate in this program. As a Ritter agent, you’ll also have access to a team of knowledgeable sales reps for support through policy changes as more.
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