In this episode of Diabetes Care Conversations, we explore Medicare's new BRIDGE model and what it means for expanding access to obesity medications for eligible beneficiaries. Hannah Martin is joined by Cristy Gallagher, MPH, Coordinator of the Obesity Care Advocacy Network (OCAN), to discuss how the model works, who qualifies, and why continued advocacy is essential to making comprehensive obesity care more accessible and permanent.
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Hannah Martin
For over two decades, Medicare has excluded coverage of medications used to treat obesity, but that's beginning to change. A new Medicare demonstration model is opening the door to obesity medication coverage, making one of the most significant federal policy developments in obesity care in years. Hello, and welcome to ADCES's podcast, Diabetes Care Conversations.
In each episode, we speak with guests from across the diabetes care space to bring you perspectives, issues, and updates to elevate your role, inform your practice, and ignite your passion. I'm your host, Hannah Martin, ADCES's Director of Advocacy. Our guest today is Christy Gallagher, the coordinator for the Obesity Care Advocacy Network. Christy joins us to explore what the new bridge model means for people living with obesity, the healthcare professionals who support them and the ongoing advocacy efforts aimed at making access permanent. Christy, welcome. I'm so glad you're here.
Cristy Gallagher
Thanks Hannah. I'm happy to be here.
Hannah Martin
Before we dive in, can you introduce yourself and share a bit of your background?
Cristy Gallagher
Sure. I am the coordinator for the Obesity Care Advocacy Network, which is a coalition of other organizations that have been working together to improve access to obesity care for over a dozen years or so. And ADCES is one of our members. I also serve as the Associate Director of Research and Policy for the Stop Obesity Alliance. Which is located within the Milken Institute School of Public Health at George Washington University.
Hannah Martin
Medicare has just launched its highly anticipated GLP one BRIDGE model. Can you give us an overview of the model and why CMS is doing this?
Cristy Gallagher
Well, it is exactly as the name sounds. It is a bridge to care. So it is a bridge that will provide obesity care medications, specifically GLP one medications, to people living with obesity who are on Medicare Part D plans.
Hannah Martin
And so why are we doing BRIDGE?
Cristy Gallagher
So BRIDGE has been a way for the administration to expand obesity medications to Medicare recipients. And that's because since the beginning of when the Part D, which is also the pharmaceutical benefit for Medicare beneficiaries, was signed into law, it prevented any type of coverage for weight loss or weight gain medications.
And so as a way to get around that, we've been trying to come up with different ways to help the administration think about how they can expand this coverage. And this is a way for them to do it under a demonstration project. So the administration has the authority under what's called the 402 authority to do a short-term demonstration project, which will allow them to gather information about what this coverage looks like in this population.
And hopefully use that to expand coverage in the future.
Hannah Martin
So that's how we got here. This is kind of a workaround that Medicare is doing. And now that it's finally here, we're actually recording this the day after Bridge has launched. How do Medicare beneficiaries get access to obesity medications through the model? And especially for our audience, what do healthcare professionals working with beneficiaries with obesity need to know?
Cristy Gallagher
Sure. So one of the things that we have learned and that was ruled out yesterday is that this process will begin pretty much with the provider sending the prescription over to the pharmacy. So obviously the first step is for the patient to have an appointment with the prescriber or the provider. And then once they make the decision that yes, they are eligible for this and that they want to go ahead and start this medication, they will have the provider send the prescription over to the pharmacy of their choice. There's not a specific pharmacy or a limitation of pharmacies that can participate in this program. So once the pharmacist gets the prescription, and it's best if the prescriber actually writes somewhere on the prescription to send to the bridge program, then the pharmacy will go through the process of getting the approval through the central processor.
Who is Humana? So that's a process that should pretty much happen in the background. We've had a few beneficiaries and older Americans that have been concerned about things like, am I going to get denied? Or do I have to get denied first? That really should all happen in the background. It should happen between the pharmacy who will send the prescription to Humana. Humana will then actually deny the prescription. But that's also in the approval process of them saying, this patient is a Part D patient, they are in Medicare and they are eligible to sign up for BRIDGE. Then the pharmacist will go back to the provider and ask them to complete the prior authorization form. Then that form will go back to the pharmacist who will send it to Humana. And they have promised a 72-hour turnaround for them to get that information back to the pharmacist who will then dispense the prescription.
And there's actually three types of medications, GLP1s, that can be covered under this model program. One of them is Wigovi, and that's all doses of Wigovi, both the pens as well as the new pill. Then the Zeppound, but for Zeppound, it is just the quick pen is only covered. And then the new prescription called Fondeo is also covered in all doses.
So then at that time when the patient knows that their prescription is ready, they will go to the pharmacist or the pharmacy and they will pay their fifty dollar copay, which is a fifty dollar copay per month per prescription, and they will get their medication. They won't need to get another prior authorization for the entire time that the bridge program is in place, which actually is about an 18 month time period. It ends at the end of 2027.
And then they will just get their prescription renewed every month. And they will hopefully be followed by their provider to see how they're doing. And hopefully they will also be given a lot of information about maybe a nutritionist or dietitian that they could go see, other programs that might be helpful for them, maybe a program like something at a YMCA that might be helpful for them. They're gonna want to start exercising and moving more, they're gonna wanna make sure that they're monitoring their food intake and all those things that happen when you start a new medication.
Hannah Martin
So let's talk about who is eligible because I've heard you've got to be on a specific kind of Medicare plan and then also the clinical criteria.
Cristy Gallagher
Right. So the patients that are eligible are those that are already on a Medicare Part D plan. So as long as they are in a Part D plan, they can be eligible for this. That doesn't mean that this goes through their Part D plan. This is a completely different program. It kind of goes the way I think of it is above and beyond their Part D plan. So it's kind of laid on top of it. But as long as they're in a Part D plan, they are eligible. Then they have to meet
Certain clinical criteria. So if you have a BMI of 35 and above, you are eligible. If you have a BMI of 30 to 35 with certain comorbid conditions, you are also eligible. And then if you are in between a BMI of 27 and 30 and you have prediabetes, you are also eligible. So all that clinical criteria is listed on the CMS website, and you can see there on the website all of the different comorbidities that you have to have if you're in between those different levels of BMIs.
Hannah Martin
This sounds like a a mix of a lot of people are gonna have to figure it out, but there is gonna be tremendous increase in access. So hopefully this kicks off smoothly. I guess we'll know in a few weeks, right, how it's going.
Cristy Gallagher
Yeah, there is one thing to say also about the fact that there are some people that are not eligible. And that is that if you are already on one of those GLP1 medications for another condition and you are getting your medication through the Part D plan, you will continue to get your medication through that Part D plan. And those are three conditions that are already approved by the FDA for one of them is for type two diabetes.
The other one is for moderate to severe sleep apnea. And then the third one is for MASH, M-A-S-H. That is sort of the new term for what used to be non-alcoholic fatty liver disease. So it's essentially a liver disease. And if you are already getting your medication through part D, you will continue to get it through them.
Hannah Martin
So you mentioned earlier how this is a temporary around 18 month pilot program because Medicare isn't technically allowed to cover obesity medications for obesity specifically under Part D. And that's been in place the whole time it's been around, over two decades. But this almost wasn't the case. We almost got full coverage. And I'd love for you to share what happened with the rule that came out at the end of the Biden administration.
Yeah, just in the last weeks and then what happened to that proposal that sort of led us to where we are now?
Cristy Gallagher
Yes. And so for advocates like you and I who've been working on this for a very long time, we had a very exciting moment in November of 2024. I believe it was after the election. Yes, it was right very close to Thanksgiving.
Hannah Martin
I think it was like the day before Thanksgiving or two days before Thanksgiving. Yeah.
Cristy Gallagher
Yes. When we woke up to the news that the current administration at the time, the Biden administration, had proposed a rule, it was actually part of another Medicare rule and it was kind of wrapped up into that, that they were going to change the way that they viewed these medications, not looking at them any longer as weight loss medications, which is where the prohibition comes from, but instead as obesity medications and that they would be covered under Medicare and that that program would start, I think it was they were going to give in about a two year time before it actually kicked in. But we really were very close to getting this done. And so all of us who've been working on this, a lot of the advocates wrote in sending, you know, really strong comments to the administration that they were very supportive of this. But what happened in between then was the new administration came in, the Trump administration, and so we went from convincing the Biden administration to now having to convince the Trump administration. And that was a bit of an uphill battle for lots of different reasons. But one of them really was that they believed that they were going to have some legal challenges to the rule and they were reluctant to look at making it a final rule under their first few months in office, essentially.
And so when it came down to the final rule in April of 2025, they came out and said they were not gonna keep that part of the rule in. So we were disappointed, but we still felt like we had had at least made some headway in being able to talk to a new administration about why this is important. We were able to show how many older Americans really supported this and Medicare beneficiaries were really supportive of this change. And I think that that influence helped us get to the point where we are now. So when the administration met with the different manufacturers of these medications and came up with an agreement on the price, there was also an agreement that there would be coverage made available through a demonstration program. And that's how we got to the bridge program.
Hannah Martin
And that sort of circumvents or I guess doesn't run into the same legal problems they were worried about the original rule, because Congress said Medicare Party can't cover drugs for weight loss. And we had been arguing and legal folks had been arguing that treating obesity and weight loss are not the same thing when there's a disease, one's not a disease. And then you get into like weight maintenance versus weight loss, but we're here, we're trialing it. No one from what I've heard is worried about any legal challenges to this. So hopefully it'll be smooth sailing for the next eighteen months. But speaking of Congress, I wanna jump over to them because they've been thinking about this for a long time as well. And it may seem like you gave this great history on the regulatory side that this just popped up out of nowhere in 2024 with the Biden administration. But really this has been many years of advocacy that you and I have both been involved in, focusing pretty heavily on Congress. So let's jump over to Congress and talk about their role in this and what they've been up to.
Cristy Gallagher
That's exactly right. So Congress has introduced legislation called the Treat and Reduce Obesity Act. And hopefully many of your listeners are familiar with this because it is something that you all have supported for many years. We also call it TROA. So if you hear me slip into that, that's where that acronym comes from. So TROA has been introduced with many different supporters over the years. What it would do in regards to coverage of obesity medications, is basically change that statutory language that prevented weight loss medications from being covered by Medicare. It's a pretty simple change. It would just open the door for Medicare then to do the coverage. Medicare could then make different decisions about how that coverage happens, but the Treat and Reduce Obesity Act has not been passed so far.
The closest we got was last Congress. I believe it was around the same time of year, where we finally got it through one of the committees on the House side. But it was reintroduced again this Congress and has not moved very fast this Congress, other than we do have several supporters. So that is good.
Hannah Martin
Several, I think you mean like a hundred plus too. Yes, sorry. We don't want to undersell I want our audience to know like it's been a very popular bill in Congress, but they have struggled to move it forward nonetheless. And there's actually a second part of the bill I'd love for you to talk about. So it doesn't just fix the Part D piece, it also improves access to obesity counseling in Medicare too.
Cristy Gallagher
And from what I understand, this was actually the first part of the Treat and Reduce Obesity Act that was focused on by many of our advocates. And that is that it would expand the way that intensive behavioral therapy is covered under Medicare. So the intensive behavioral therapy benefit was passed, I believe, sometime around 2010 or so. And that essentially gives reimbursement to primary care providers for providing counseling for people living with obesity who are in Medicare. So it's a pretty standard benefit, but what happened was when they passed this legislation, or I guess it was a rule that the benefit only goes to reimburse primary care providers or those in a primary care setting. So that leaves out a lot of other providers that could provide this benefit. And we've been working with all of our members at OCAN, and that includes everyone from endocrinologist to psychologist to nutritionists and dietitians and many others that would be able to provide this benefit and would really need to get reimbursed. And one of the ways that we've been able to tell that it is so underutilized is by looking at the uptake of that benefit. So the last I heard, it's really been in a like the single digit percentages of the number of people on Medicare that actually get this benefit. But when you think about it, Hannah, if you have people that are on GLP ones, this is the most important benefit that they could get alongside that. And I'm really kind of concerned about the number of people that we are going to have on GLP ones under the Bridge program on Medicare who are not going to be able to get this IBT benefit. So it's something that we really are trying to work on hard. But yes, this part of it would be fixed if we got TROA passed.
Hannah Martin
Yeah, most of our members are going to be very familiar with the diabetes self-management training benefit in Medicare, where if someone has any form of diagnosed diabetes, they get, at least in their first year, a pretty good number of hours, 10 hours to meet with a diabetes care and education specialist. And there are a lot of hours available in IBT for obesity, but I just really wanna underscore what you said. Only primary care providers in a primary care setting can bill for it. So I was actually one of the co-chairs of a work group that we had when you first took over as coordinator in OCAN, where we petitioned, this is gonna get a little wonky, just a warning. We petitioned for Medicare to reconsider its coverage determination. So Medicare looked at US Preventive Services Task Force rulings and made a benefit from it. And we think they missed the mark with the evidence you can survey primary care providers and they mostly say they don't want to be the ones doing this. They would love to be able to refer to people with specific training in weight management, whether that's other physicians, PAs and NPs working in obesity medicine, dietitians, psychologists, many others who just have deep expertise in weight management. And they can't do that right now. And so we've asked Medicare formally if they could do this without Congress telling them to. We've asked them to reconsider that. And the a coverage analysis group put us on their wait list, which sounds like a crazy thing to be excited about, but getting on the wait list can take a decade or more. And we worked on this. I personally started working on this project in 2020. And when did we submit that? Was that spring of 2025, I think?
So it was probably five years, half a dozen or more organizations. It's a big document. We got to flex our our wonky muscles there a little bit. So that also is sort of sitting out there alongside the bridge program as something Medicare could advance. We just don't know the timeline for that. So we're just pushing on all the different avenues until then.
And because we're both advocates, I would be remiss if I didn't bring up the opportunities that listeners have to get engaged in this and use their voice to advance these issues in Washington. I'll first plug the ADCES Legislative Action Center, which allows anyone open to the public to send pre-drafted messages to their members of Congress about issues that are important to ADCES members, including TROA, which we have an action alert up for now.
So I'd invite all of our listeners to look at the resources under this episode for the link to that, the ADCS Legislative Action Center. Christy, there's more out there that listeners can plug into. What else should they be looking for to engage with?
Cristy Gallagher
So the Obesity Care Advocacy Network does have an advocacy tab on our website. And we list some of the other organizations besides yours that have those type of avenues to reach out to their members of Congress and advocate for certain pieces of legislation, in particular TROA. So that's one avenue. And I'd like to point out one of those organizations.
That has been very active in all of this, and that's called the Obesity Action Coalition. So OAC has a wonderful website where you can get all kinds of information about other advocacy opportunities, as well as learn a lot about people living with obesity, the treatments for obesity. They even have a provider network. But in this case, if you are interested in advocating, I would look at their website and see what is possible in your area. The American Diabetes Association also has some local advocacy opportunities. And so they would be another place that I would look and see if there's something there that matches up with the city or the state that you live in, because there are all kinds of activities happening all across the US right now, whether there's coverage, whether there's not coverage, there's different types of legislation that would expand access to care. And we would love to have your voice.
Hannah Martin
And for ADCES members, I'll also plug the ADCES Public Policy Forum. It just happened a few weeks ago in late June, but TROA was one of the bills we were advocating for. That usually takes place in June. So keep an eye on our website and on the newsletter for information about that. And we also trained advocates in 2024 on what it looks like to advocate for obesity care at the state level within Medicaid.
And you can find below a link to the recording to our 2024 state policy forum to learn more about that. All right. We are coming to the end of our time. And I want to invite you, Christy, if listeners could just take away one message from this episode. What would you want it to be?
Cristy Gallagher
I think I would like your listeners to think about how potentially bias and stigma enters into care for people living with obesity. And all of this advocacy work that Hannah and I have done, it really stems back to the fact that people with obesity have not been treated as though they are living with a disease. And because of that, there have been, you know, strange things that have needed to have go arounds like the intensive behavioral therapy benefits or the access to medications. We haven't even talked about access to bariatric and metabolic surgery, but all of the continuum of care that is out there for people with obesity needs to be expanded and we need people to have access to that care. So I would just think about, you know, if you see that bias and stigma coming up with others that you work with, call them out on it. Maybe pull them aside, talk about how we talk about people living with the disease of obesity, not people that are obese or people who have morbid obesity. That's really kind of one of the things that I like to level set with people when they're thinking about expanding access to care. Because we don't have many other diseases that we have to show either a return on investment, a cost benefit analysis or even to try and fight Congress to try and get expansion of care. So that's the one thing that I would hope people will remember.
Hannah Martin
I would second all of that and just add on top of it, because of all of those barriers with stigma and inertia and just lack of access being sort of the norm in obesity, the launch of the bridge program is actually a historic milestone. There are quite literally millions of people who, as of two weeks ago, when you're listening to this episode, gained access to really exciting medications that have shown just to change lives. And that didn't happen overnight and it's not permanent yet. So there's still a lot of fighting to do. But hopefully our members will be fighting the good fight in the clinic to get people the care they need and in Washington to make this permanent. Thank you for listening to this episode of Diabetes Care Conversations Engaging with ADCES.
You can find any resources related to this episode in the show notes. And remember, being an ADCES member gets you access to many resources, education, and networking opportunities, and directly supports the association's advocacy work. Learn about the many benefits of ADCES membership at adces.org slash join.
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