Tier 2: BMI 30+ plus one qualifying condition
Published by GLP-1 Coverage Guide · Updated · No clinician review is credited for this page.
Short answer: With a BMI of 30 or higher, you qualify for the Medicare GLP-1 Bridge if you also have at least one of three conditions: chronic kidney disease at stage 3a or beyond, heart failure with preserved ejection fraction (HFpEF), or high blood pressure that medication hasn't brought under control. One condition is enough — you don't need all three.
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.
The three Tier 2 qualifying conditions
Chronic kidney disease at stage 3a or higher — meaning kidney function (eGFR) has declined to about 59 or below. Many people with early-stage CKD don't know they have it; it's identified from routine bloodwork your doctor may already have.
Heart failure with preserved ejection fraction (HFpEF) — this is the specific heart-failure diagnosis CMS lists. Heart failure with reduced ejection fraction (HFrEF) alone does not satisfy this condition requirement; you may still qualify through another published eligibility path.
Uncontrolled hypertension — systolic blood pressure above 140 mm Hg OR diastolic above 90 mm Hg despite concurrent treatment with two antihypertensive medications. Merely being above an individual treatment goal is not the published criterion.
If you're BMI 30+ without these conditions
You may still qualify: the Tier 3 conditions (prediabetes, a prior heart attack or stroke, or symptomatic peripheral artery disease) apply at BMI 27 and up, which includes you. Ask your clinician to confirm any diagnosis using your medical records; a single lab value is not an eligibility decision.
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 controlled high blood pressure count?
No — the criterion is hypertension not controlled by medication. If your readings are at goal on your current prescription, this particular condition doesn't qualify you, but check the Tier 3 conditions, which also apply at your BMI.
How do I know my CKD stage?
Ask your doctor for your eGFR number from your most recent bloodwork. An eGFR of 59 or below generally corresponds to stage 3a or higher.
Do I need to prove the condition?
Your provider documents the diagnosis in the prior authorization they submit to the program's central processor. You don't submit anything yourself.
Related
Criteria source: CMS provider guidance: BMI at therapy initiation · CMS prior authorization form