GLP-1 Bridge Access Gaps Frustrate Patients: Fatima Cody Stanford, MD

The Medicare GLP-1 Bridge program was meant to expand access to obesity medications for older adults, but administrative complexity, narrow eligibility criteria, and a cost-sharing structure that leaves many patients outside the program paying hundreds of dollars a month are undercutting that goal, according to Fatima Cody Stanford, MD, MPH, MPA, an obesity medicine physician at Massachusetts General Hospital and associate professor of medicine and pediatrics at Harvard Medical School.

In part 1 of this interview with The American Journal of Managed Care® (AJMC®), Stanford discussed the operational burden the Bridge program places on clinicians and pharmacies, how the flat $50 copay compares with the out-of-pocket costs patients face when they don't qualify, why the program's eligibility criteria exclude many patients who could benefit, and what a lack of awareness about the program means for equitable access to glucagon-like peptide-1 (GLP-1) receptor agonists for obesity treatment.

This interview has been edited for clarity.

AJMC: Since CMS's Medicare GLP-1 Bridge program launched in July, what are you really seeing on the ground? What's going smoothly, and where is there friction?

Stanford: I like the program's intent. The intent was to cover older adults who have overweight and obesity, which is an important demographic, particularly if we look at GLP-1s. We know that these medications reduce major adverse coronary events, but the infrastructure isn't really set up to support this program well. There are a lot of things that have to happen on the side of the clinician and their office. The prescription must include a note stating, “This is for the Medicare Bridge program,” along with the indication. The indications include prediabetes and hypertension on 2 medications, among other criteria.¹ If the patient has ever had a prescription through Medicare or has ever had any coverage for a GLP-1, they're going to be denied. But the clinician has to know that this needs to be included on the prescription as it's sent to the pharmacy. Then, of course, there needs to be a prior authorization request for the Medicare Bridge program, so multiple steps need to be taken.

I work in a specialty clinic, so from day 1 we said, “Okay, we need a process for this.” There is information that needs to go out to our patients outlining the eligibility criteria for the Medicare Bridge program, and we need to know what happens on our side to send it to the pharmacy. There are checks and balances that need to be in place. But what if you're in a primary care setting, which is what most people are, or in a specialty clinic that isn't specializing in obesity care specifically? The ball is dropping all over the place, and this is making it very prohibitive for individuals who really need to access this care to get the medication.

The patient might think, “Well, I have obesity. I see this commercial with a celebrity on TV, and I'm one of those older adults who has obesity. I should be able to get in.” Then you find out they don't meet the criteria. They don't have prediabetes or they do have hypertension, but they aren’t on 2 medications. All of these things push the patient out of coverage, leaving them stuck without it.

Or say they have obstructive sleep apnea. They still need to meet their copay or deductible. They are paying $500 a month to meet their $2100 deductible to get the medication that a friend is getting for $50 a month. Those are the issues we're running into. That's what's happening on the ground.

AJMC: You mentioned that $50 copay — it's a flat amount that doesn't count toward the deductible or out-of-pocket cap. What does that mean in practice for patients and their long-term costs?

Stanford: For patients who are covered under the Bridge program copay, it's my understanding that they'll have a $50 copay for the medication. Those who don't meet the requirements for the Bridge program will have relatively high copays.

Let me give you a real scenario that happened. I had a patient I saw in the office who has moderate to severe obstructive sleep apnea, which is also an indication for tirzepatide [Zepbound; Eli Lilly]. Her copay for the medication under her Medicare plan is about $450-$500 per month until she meets her deductible cap, because obstructive sleep apnea isn't one of the Bridge criteria and she isn’t eligible for the program. Once she meets that cap, her medication cost goes to $0.

But she doesn't have that amount of money on her limited income. She doesn't just have the money to readily pay to get the medication so she can meet her cap for 4 or 5 months. So, she foregoes the medication not because she doesn't want it, but because she has to pay for things like food and housing instead.

Someone like her goes without the medicine. Now, compare that to someone in the Medicare Bridge program: Their out-the-gate amount is $50 a month, and they can apply that to their cap.

AJMC: How well do the eligibility criteria map to the patients you'd actually want to treat and get access?

Stanford: As a specialist in obesity, I'd say it doesn't map as well as I would like. I care for the full gamut of patients with obesity. I don't just take care of patients who have prediabetes or hypertension on 1 or 2 medications or a history of heart disease, which are part of the other Bridge program's criteria. It limits what I can provide, and about a third of my patients are older adults.

I feel quite hurt, honestly, because I have such a high level of empathy for my patients. When I'm unable to get them on this program because they don't meet these criteria, I must tell them, “I'm sorry, it looks like you're going to still have to pay out of pocket.”

I'll use a real example: Let's say I was able to get a patient on a plan that covered dulaglutide [Trulicity; Eli Lilly]. It's not a medication approved for obesity, but we were trying to use a GLP-1 to get them some benefit, some coverage, through whatever method we could. Now that the Medicare Bridge program is available, they do have prediabetes, so maybe they'd be covered, but because they had prior coverage of any GLP-1, they no longer meet eligibility for this program. They have a historical use of GLP-1 in the remote past, so they don't meet the criteria. The rules often don't allow us to get coverage for people who really do meet the criteria for the medications. There's a lot of red tape.

AJMC: Can a patient who started a GLP-1 through the Bridge program lose eligibility? And if so, how would you counsel them through that?

Stanford: It's not that they lose eligibility, it's that this program right now is only authorized through December 31, 2027. I wouldn't say we're seeing many people lose eligibility per se, because the time span we're looking at is so short. It's already taking quite a bit of time to get them approved, so by the time they're approved, they're on therapy for 14 months, and then the program is gone.

That's where I'm concerned. If we look at the utilization of these medications—semaglutide [Wegovy/Ozempic; Novo Nordisk] or tirzepatide [Mounjaro/Zepbound]—the study duration for those medicines is 68 to 72 weeks.³ We haven't met that criterion; we're not looking at the duration that corresponds with the best clinical outcomes for these medications. What happens on January 1, 2028? What are we going to see?

If we look at John Wilding's discontinuation study for semaglutide⁴ and Louis Aronne's discontinuation study for tirzepatide,⁵ we know what happens when we withdraw these medications: patients regain weight. And it's not just about regaining weight; we also see a re-emergence of the cardiometabolic diseases associated with their use.

Which group is most likely to have the worst outcomes? Older adults, who over their lifetime have likely accumulated cardiometabolic disease, are at the top of that list, along with kidney outcomes, for the risk of adverse coronary events, stroke, and heart attack. All of these things accumulate over one's life. Older adults are at the greatest risk. If we pull these medications back, then those things that may have improved over time will likely re-emerge, and that's where I'm most concerned.

AJMC: Commercial payers and employers watch government programs pretty carefully. Is a flat copay model without standard prior authorization something we might see move into commercial coverage? Are there specific lessons from this rollout?

Stanford: I don't think we're going to learn anything great from this program in terms of how it applies to commercial payers. It feels similar to what an employer-sponsored insurance program already has to do, maybe even a little more, because you have to add that additional note to the prescription and take an extra step. That's probably similar to prior authorization under employer-sponsored insurance.

I would say that yes, we look to Medicare: If Medicare covers something, employers say, " Well, Medicare covers this, we have to cover this too,” because they have to do better than what the government is doing. But I wouldn't say there will be any major lessons learned here. I'd say it feels clunkier, or more arduous, than employer-sponsored insurance, but not significantly. They're on par with each other, with maybe 1 additional step in what needs to be included in the script for coverage, which we don't have to do with employer-sponsored insurance coverage for patients with overweight and obesity.

AJMC: Looking beyond eligibility criteria, who's more likely to get left behind by this Bridge program in practice, despite being eligible? How do we close that gap?

Stanford: Right now, I think there are a lot of people who are going to get left behind. For instance, anyone who isn't in more specialized care, because this is so much work. When I'm talking to larger populations through media, people reach out to me through different channels, and what I'm hearing from the general population is that they've tried to speak with their primary care physician or subspecialist—whether endocrinology, cardiology, or nephrology—and it's a lot of work or burden on those staff, whether in academia or private practice. They just don't know how to do the work: What are steps 1, 2, and 3? Even some of my colleagues at well-oiled academic institutions are asking, “What do I have to do? Does this program exist?” There's a lack of awareness of the program's existence and the steps needed to ensure the eligible population understands the criteria and actually gains access.

There wasn't a handout that went out to people saying, “Here's the patient population, here's step 1, step 2, step 3.” And I think part of why that is because the already burdened system would become even more overburdened. If everyone knew about the program and knew how to do it, how would the system even handle that volume? If only a few of us really know how to do it well, the system can handle that. But if every primary care physician and every subspecialist who takes care of older adults really knew how to do it, the system would crash.

References

1. Weight loss drugs. Medicare.gov. Accessed October 14, 2026. https://www.medicare.gov/coverage/weight-loss-drugs
2. CMS launches Medicare GLP-1 Bridge, expanding access to GLP-1 medications. News release. CMS. July 1, 2026. Accessed October 14, 2026. https://www.cms.gov/newsroom/press-releases/cms-launches-medicare-glp-1-bridge-expanding-access-glp-1-medications
3. Aronne LJ, Horn DB, le Roux CW, et al; SURMOUNT-5 Trial Investigators. Tirzepatide as compared with semaglutide for the treatment of obesity. N Engl J Med. 2025;393(1):26-36. doi:10.1056/NEJMoa2416394
4. Wilding JPH, Batterham RL, Davies M, et al; STEP 1 Study Group. Weight regain and cardiometabolic effects after withdrawal of semaglutide: the STEP 1 trial extension. Diabetes Obes Metab. 2022;24(8):1553-1564. doi:10.1111/dom.14725
5. Aronne LJ, Sattar N, Horn DB, et al; SURMOUNT-4 Investigators. Continued treatment with tirzepatide for maintenance of weight reduction in adults with obesity: the SURMOUNT-4 randomized clinical trial. JAMA. 2024;331(1):38-48. doi:10.1001/jama.2023.24945