Tier 3: BMI 27+ plus one qualifying condition
Published by GLP-1 Coverage Guide · Updated · No clinician review is credited for this page.
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.
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 four Tier 3 qualifying conditions
Prediabetes — blood sugar above normal but below the diabetes threshold (A1c of roughly 5.7–6.4%). A clinician must confirm the diagnosis. 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. Ask your prescriber to check starting criteria and the intended prescription indication; a potentially qualifying history does not guarantee Bridge coverage.
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
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 provider guidance: BMI at therapy initiation · CMS prior authorization form