Oral GLP-1s, Medicare Bridge Reshape Obesity Care: Holly Lofton, MD

New oral glucagon-like peptide-1 (GLP-1) agents, an expanded Medicare pathway, and broader label indications have widened access to obesity pharmacotherapy over the past 18 months—but weight bias among clinicians and patients themselves still keeps many eligible patients from ever starting treatment, said Holly F. Lofton, MD, clinical associate professor of medicine and surgery and director of the Medical Weight Management Program at NYU Langone Health.

In the first part of an interview with The American Journal of Managed Care® (AJMC®), Lofton discussed how label expansions into weight-related conditions like MASH and sleep apnea have opened commercial coverage doors, how the new Medicare GLP-1 Bridge program¹ is affecting older patients who previously had no coverage pathway, and why weight stigma in clinical settings² continues to suppress treatment even among patients who qualify. She also compared how the 2 available oral GLP-1s, the semaglutide (Wegovy; Novo Nordisk) pill³ and orforglipron (Foundayo; Eli Lilly),⁴ differ in formulation and who they fit best.

This interview was edited for clarity.

AJMC: The obesity treatment landscape has shifted recently with new oral agents, a Medicare demonstration program, and expanded label indications. What would you say is the single biggest change in how you're actually practicing obesity medicine right now compared with 18 months ago?

Lofton: I think you have the timeline right on the head of the nail, because about 18 months ago we started to see some shifts in access and also in patient willingness to consider GLP-1s. The first of those, I think, would be the label expansions, because we have many patients with commercial insurance who have coverage for medications for many conditions, but not obesity. This allowed us, as prescribers, to look further into the weight-related conditions like heart disease; MASH [metabolic dysfunction–associated steatohepatitis], previously known as fatty liver disease or hepatic steatosis; and sleep apnea, because insurance providers tend to be more willing to allow access by coverage for the GLP-1s to patients in these classes if they specifically exclude weight management medications.

I think this also led to the change with Medicare. Now we have the GLP-1 Bridge Program,¹ which is monumental for weight loss. I've been doing weight management for it'll be 20 years in January, and we always said, “Sorry, patients with Medicare, you don't have access. You'll have to pay, or you just don't receive the medication.” Now this has helped our seniors, or our Medicare recipients, be able to have access to medications for weight management. These people worked all their lives to contribute to Medicare and then don't have access to medications that they might have previously had with their commercial insurance or that they need to have a healthy and fulfilling retirement. I think that access has really been monumental for our patients with Medicare. And even though it takes a few more steps to get it done, it's definitely worth it for those patients.

And then lastly, the oral agents. We have patients who would be called needle-phobic and I absolutely would not do any injection: “I don't care how often it is or how little it hurts; it's not for me.” Bringing the oral agents to the table, I've really seen patients come in and say, “I was waiting for oral, here I am. I'm ready to address my weight with medications, but the oral is my preference.” And we've been able to help patients get these. Also, the prices have dropped. That's a big difference from even a year ago, when we were talking close to $1500 for some of the GLP-1 injectables,⁵ and now we see monthly self-pay rates as low as $150 a month for patients who still have only access to self-pay.⁶

AJMC: Most medical bodies formally recognize obesity as a chronic, relapsing disease, but payers still cover it episodically. Where do you see the disconnect causing the most harm in patient care when it's not being covered the way we'd like to treat it?

Lofton: I think that the gap between patients who are candidates for medications and patients that have access is still very large. When we look at the number of patients who are eligible for a GLP-1—even if we look at the highest class of obesity, class 3, which is BMI [body mass index] 40 and up—only 10% of those patients actually receive a medication for weight management. It's not only the insurance coverage that's limiting access, but it still has a lot to do with weight bias, where patients think: One, I should be able to do this on my own. Two, I have a health care provider who doesn't support it, so I'm not going to look into it any further. And 3, there's also a lot of misinformation about using GLP-1s, or incretin mimetics, that scares people away from even having the conversation with their doctor. I think all of these cause patient harm, because we recognize this as a disease, but if we're limiting access, we're not making a dent in the epidemic that we still have.

AJMC: You mentioned weight bias in terms of how patients might think about seeking or not seeking treatment. But it also remains a barrier among treating clinicians. How often would you say that bias shows up in decisions about who gets offered pharmacotherapy in the first place, and how do we meaningfully change that?

Lofton: Weight bias is extremely prevalent,⁴ especially in a health care setting, because research has been done looking at doctors, nurses, psychologists, and even registered dietitians about their attitudes toward people with obesity. Sometimes it's that they think patients aren't trying hard enough—I'll use these terms from research trials—that they're “futile to treat,” that they're “lazy,” and this can lead to the conversation not even being had about the option of medications for weight management.

Where I see this shifting now, this external bias where the provider is projecting bias onto the patient, is that I've seen more providers say, I won't prescribe to you, but I will send you to the weight management center. Maybe they will. At least that's opening the door to a patient who just has a primary care provider or gynecologist, some other doctor they like who just does not agree with prescribing the medications. They know that the option of referral is there, whether they're seeing a person in the office or using a vetted telehealth platform, because we know there are deserts that exist in the nation regarding access to weight management medications.

Then there's the internal weight bias, where a patient has been a victim of weight bias for so long that they internally just avoid the medical system because they've been told that they're fat, that we can't treat you at this weight, that you need to lose weight on your own, and that you should be able to lose weight if you really try and you're not trying hard enough. That can make the patient not only avoid the medical weight management center but also their regular preventive tests—Pap smears, mammograms, just getting lab work yearly with their primary care—because they've internalized this weight bias and feel that it's their fault and that they don't deserve to be treated medically, which is absolutely not true.

It's interesting, because obesity or overweight is a condition where the majority of Americans have one of these, yet we still put bias on people who have it. They say, “Well, this person is overweight and they're taking a drug, and I don't agree with any of it.” So, you get bias from many different directions. And then patients may think, “I'm not heavy enough to be considered for weight management medication.” We have to keep in mind that it's based on not only weight, body fat percentage, and waist circumference, but also how your medical health is. I think it's good to have a conversation before excluding yourself from even being considered for that, because of internalized weight bias.

AJMC: Circling back to the oral GLP-1s that are now available, there are 2—Novo's semaglutide (Wegovy) pill and Eli Lilly's orforglipron (Foundayo)^3,4—joining the injectables that are already on the market. How do you think about where an oral agent fits versus an injectable for any given patient?

Lofton: You have to think about how medication administration fits into a patient's lifestyle. For some people, a weekly injection is easier to remember and administer, and they just pick a day of the week and they take it. Because the injectables need to be refrigerated, that does present some challenges for some patients. I had this with a patient earlier today, actually, where she was taking the injectable, and because she travels sometimes for a month at a time, she wasn't able to keep it refrigerated. There were temperature excursions, and the medication became ineffective; she'd have to lower the dose, and we really never got to a great treatment dose. In that setting, we switched her to an oral medication, which doesn't have the refrigeration needs—it still needs to be at room temperature, but you don't have to keep it cold, and it's much easier to travel with.

And again, those patients who are averse to needles don't want to do needles. This hasn't happened yet, but I think opening up the oral market to adolescents with obesity will be a big change we'll be seeing soon, because many parents are willing to treat their child's weight but aren't thinking of an injection for their child if they're 13 or 14 years old, even though the injectable, Wegovy specifically, is approved for ages 12 and up.

AJMC: Can you explain how the 2 oral agents differ in terms of data and daily administration logistics? How might that factor in?

Lofton: I'll start with the Wegovy pill. It's important to know that the Wegovy pill is the same scientific makeup as the Wegovy injection. In order to make it available to be absorbed through the stomach, they've engineered the pill in a very special way, where they attach what's called a SNAC [sodium N-(8-[2-hydroxybenzoyl] amino) caprylate], which is essentially an oral absorption enhancer. In the pill, you have semaglutide and the SNAC. When that's taken with 4 ounces of water and it sits in the stomach for 30 minutes, which is the correct administration of the Wegovy pill, it changes the acidic environment of the stomach such that the drug can be absorbed, which is unique to it. That's why it has the administration limitations: it has to be the first pill you take in a day with 4 ounces of water, and then you need to wait 30 minutes before anything else goes into your stomach. Also, because these drugs go through the stomach and some degree of hepatic metabolism, there's less absorption than with the injection, which means you generally need more medicine in the pill to get the same blood levels as the injection.

Then, looking at Foundayo, it's also a unique GLP-1 in that it's a small molecule rather than a peptide. If you look at the chemical structure of Foundayo, it doesn't look like a peptide with a fatty acid tail—instead, it's little ring structures, and that's what makes it available orally. But it doesn't have any restrictions on taking it with or without food or how much water you can have. So, I find this better for patients who have work schedules that change shifts, or, say, college students who may not have a refrigerator, but they don't want their medication to be visible to their roommate, things like that. They're definitely a population this is benefiting, and it allows us to treat more patients.

References

1. Hohmann E. What you need to know before the Medicare GLP-1 Bridge goes live. AJMC. Accessed September 14, 2026. https://www.ajmc.com/view/what-you-need-to-know-before-the-medicare-glp-1-bridge-goes-live
2. Kyle TK, Garvey WT, Dunn JP, Salas XR, Stanford FC. Overcoming weight bias in health care systems. Am J Manag Care. 2025;31(9):e241-e243. doi:10.37765/ajmc.2025.89788
3. Joszt L. FDA approves oral semaglutide as first GLP-1 pill for weight loss. AJMC. December 22, 2025. Accessed September 15, 2026. https://www.ajmc.com/view/fda-approves-oral-semaglutide-as-first-glp-1-pill-for-weight-loss
4. Hohmann E. FDA approves Lilly's oral GLP-1 orforglipron for obesity. AJMC. April 1, 2026. Accessed September 15, 2026. https://www.ajmc.com/view/fda-approves-lilly-s-oral-glp-1-orforglipron-for-obesity
5. Lovelace Jr B. The cost of weight loss drugs is finally dropping. How low can prices go? NBC News. May 27, 2025. Accessed September 15, 2026. https://www.nbcnews.com/health/health-news/cost-weight-loss-drugs-wegovy-zepbound-how-low-prices-down-rcna205911
6. McNulty R. Trump announces deals with Lilly, Novo to cut weight loss drug prices. AJMC. November 6, 2025. Accessed September 15, 2026. https://www.ajmc.com/view/trump-announces-deals-with-eli-lilly-novo-nordisk-for-lower-weight-loss-drug-prices