Tier 1: BMI 35 or higher qualifies on its own
Published by GLP-1 Coverage Guide · Updated · No clinician review is credited for this page.
Short answer: If your BMI is 35 or higher and you have Medicare drug coverage, you meet the GLP-1 Bridge program's first eligibility tier — no additional health conditions are required. Your provider still needs to submit a prior authorization confirming your BMI before you can fill at the $50/month rate.
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 Tier 1 means in practice
Tier 1 is the simplest path into the program. CMS set BMI 35 as the threshold at which body-mass index alone — without any other diagnosis — establishes eligibility for the $50/month copay on Wegovy, Zepbound (KwikPen), or Foundayo.
For reference, BMI 35 corresponds to roughly 217 pounds at 5'6", 244 pounds at 5'10", or 258 pounds at 6'0". Use the calculator below to check yours, and remember your provider documents the BMI at therapy initiation; a home estimate is not a coverage decision.
What you still need even at Tier 1
Three things: Medicare drug coverage (a Part D plan or Medicare Advantage plan with drug coverage), no routing condition (type 2 diabetes, moderate-to-severe sleep apnea, or MASH — those move you to standard Part D coverage instead), and a provider-submitted prior authorization to the program's central processor, which is administered by Humana.
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
Does a BMI of exactly 35 qualify?
Yes — CMS's criterion is BMI 35 or higher. If you're on the borderline, the documented BMI at therapy initiation is what counts.
Do I need diabetes or heart problems to qualify at Tier 1?
No. At BMI 35+, no additional condition is required. In fact, if you have type 2 diabetes you'd be routed to standard Part D coverage instead of the Bridge.
How much will I pay?
A flat $50 per month, with no deductible. Note the $50 does not count toward your Part D out-of-pocket cap, and Extra Help (LIS) does not reduce it.
Related
Criteria source: CMS provider guidance: BMI at therapy initiation · CMS prior authorization form