BMI 35: you likely qualify outright
Published by GLP-1 Coverage Guide · Updated · No clinician review is credited for this page.
Short answer: A BMI of 35 or higher meets the Medicare GLP-1 Bridge's Tier 1 criterion by itself — no additional health conditions required. With Medicare drug coverage and a provider-submitted prior authorization, you can fill Wegovy, Zepbound (KwikPen), or Foundayo for a flat $50 a month.
Sources for the coverage rules are listed below. An update date marks a revision; it does not imply a sitewide medical review.
Use BMI when GLP-1 therapy started
CMS uses BMI at the initiation of GLP-1 therapy, including treatment that began before Medicare enrollment or July 1, 2026. If you have already lost weight on treatment, ask your prescriber to document the starting criteria from your medical records. A lower BMI today does not replace the starting BMI.
This calculator gives an estimate, not a coverage decision. It rounds the estimate to one decimal, to match the one-decimal BMI ranges on the CMS prior-authorization form (27 to 29.9, 30 to 34.9, 35 to 39.9), and uses that same number for the thresholds; your prescriber must attest to the documented criteria.
What BMI 35 looks like, and what happens next
BMI 35 is roughly 217 lbs at 5'6", 230 lbs at 5'8", 244 lbs at 5'10", or 258 lbs at 6'0". At or above these weights, the eligibility conversation is short: confirm you have Medicare drug coverage, confirm you don't have a routing condition (type 2 diabetes, moderate-to-severe sleep apnea, or MASH — each of which moves you to standard Part D coverage instead), and have your provider submit the prior authorization to the program's central processor.
Time matters more than most people realize: the program ends December 31, 2027, with no announced successor. Starting the provider conversation now means starting therapy with the maximum possible runway at the $50 rate.
BMI at the start of GLP-1 therapy
Already taking a GLP-1? Use your height and weight when therapy first started. CMS accepts qualifying starting criteria from before Medicare enrollment or July 2026. If starting therapy now, use pre-treatment measurements. Ask your prescriber for records if you do not know.
Take the full 2-minute eligibility check →
Common questions
Is there any BMI too high for the program?
No upper limit appears in the criteria — 35 and above qualifies under Tier 1.
Do I get to choose which drug?
That's a clinical decision with your prescriber among the three covered products: Wegovy, Zepbound (KwikPen form only), and Foundayo.
Related
Criteria source: CMS provider guidance: BMI at therapy initiation · CMS prior authorization form