Tier 3: BMI 27+ plus one qualifying condition
Short answer: The GLP-1 Bridge's lowest BMI tier starts at 27 — overweight, not obese — if you also have prediabetes, a previous heart attack or stroke, or peripheral artery disease with symptoms. This is the tier most eligible people don't realize they're in, chiefly because prediabetes is so common and so often undiagnosed.
Program facts last verified against CMS: July 21, 2026
The four Tier 3 qualifying conditions
Prediabetes — blood sugar above normal but below the diabetes threshold (A1c of roughly 5.7–6.4%). Roughly half of adults over 65 meet this definition, and most don't know it. If you've ever been told your sugar is 'a little high,' ask your doctor for an A1c test.
A previous heart attack — a documented myocardial infarction at any point in your history.
A previous stroke — likewise, at any point in your history.
Symptomatic peripheral artery disease — narrowed leg arteries causing symptoms, classically cramping or pain in the calves when walking that eases with rest (claudication).
Why this tier matters
BMI 27 corresponds to about 167 pounds at 5'6" or 188 pounds at 5'10" — well within the range many people consider only modestly overweight. Combined with how widespread prediabetes is among Medicare-age adults, Tier 3 likely covers a large share of the program's roughly 3.8 million eligible beneficiaries. A single blood test conversation with your doctor can settle whether you're in it.
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Common questions
What A1c counts as prediabetes?
Generally 5.7% to 6.4%. At 6.5% or above, that's type 2 diabetes — which doesn't disqualify you from GLP-1 coverage, but routes you to standard Part D coverage instead of the Bridge.
My heart attack was 20 years ago. Does it still count?
CMS's criteria don't put a time limit on a prior heart attack or stroke. Your provider documents the history in the prior authorization.
How do I know if my leg pain is PAD?
Only a clinician can diagnose it — the classic pattern is calf cramping when walking that stops with rest. If that sounds familiar, raise it at your next appointment; an ankle-brachial index test is simple and non-invasive.
Related
Criteria source: CMS — Medicare GLP-1 Bridge · KFF