The patient must: Be age 18 or older Have eligible Medicare Part D coverage Be prescribed treatment specifically for weight reduction and maintenance Participate in ongoing nutrition and physical activity intervention Not have already received a GLP-1 through their Part D plan Not be seeking coverage for another Part D-coverable indication, such as type 2 diabetes, moderate-to-severe obstructive sleep apnea, MASH, or cardiovascular risk reduction The patient must also have met one of these criteria when GLP-1 therapy was originally started: BMI 35 BMI 30 plus HFpEF, uncontrolled hypertension despite 2 medications, or CKD stage 3a+ BMI 27 plus prediabetes, prior MI, prior stroke, or symptomatic peripheral artery disease Important: Eligibility is based on BMI at treatment initiation, not necessarily the patients current BMI
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The following sections examine the key factors behind this surge in demand, including whats driving popularity, how insurers and employers are handling coverage decisions, and what patients can expect to pay out of pocket if insurance is not available
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