4 minEconomy
Medicare’s GLP-1 pilot program leaves some patients with serious conditions behind
Medicare’s new Bridge program offers GLP-1 weight-loss drugs for $50 a month, but patients with conditions like sleep apnea or Type 2 diabetes are excluded and face much higher costs.
Jeff La Marca, a 68-year-old retired professor from Basking Ridge, New Jersey, thought Medicare’s new pilot program would finally make the weight-loss drug Zepbound affordable. Instead, his application was denied. La Marca has severe obstructive sleep apnea, a diagnosis that disqualifies him from the program’s $50 monthly price, even though his BMI is 42 and he has had quadruple heart bypass surgery.
“I’m obese, morbidly obese, BMI 42. I had quadruple heart bypass surgery. I’m at risk for stroke. I’m prediabetic. And yet I can’t get it. I’m livid,” La Marca said.
La Marca is among an estimated 5.9 million Medicare enrollees excluded from the GLP-1 discount program because they have a medical condition such as Type 2 diabetes or sleep apnea. The program, known as the Medicare GLP-1 Bridge, launched in July as an 18-month pilot. It offers coverage of three GLP-1 medications — Wegovy, the KwikPen formulation of Zepbound, and the oral medication Foundayo — for weight loss and management.
To qualify, beneficiaries must be enrolled in Medicare Part D and have a body mass index of 35 or higher. Those with a BMI of 27 to 34 can qualify if they also have conditions such as prediabetes or cardiovascular disease. But the $50 monthly price applies only to people using the drug solely for weight loss. Anyone with a qualifying medical condition that the Food and Drug Administration has approved GLP-1s to treat, such as Type 2 diabetes or moderate to severe obstructive sleep apnea, is routed back to their Part D plan, which can require copays of hundreds of dollars a month.
“The Bridge program was designed to target those people who can’t get GLP-1 coverage through Part D but would benefit from taking one for weight loss,” said Juliette Cubanski, who directs the Program on Medicare Policy at KFF, a health information nonprofit.
The federal government has not released an estimate of the program’s cost. Cubanski has estimated that 3.8 million people qualify and that, if a quarter of them enroll and remain on treatment for the full 18 months, it will cost Medicare about $3.3 billion. If three-quarters enroll, costs could rise to $10 billion. Expanding the program to include the additional 5.9 million people who are overweight and already eligible for GLP-1 coverage through Part D would add billions more.
CMS spokesperson Timothy Foster said the demonstration’s initial weeks have been positive, with most prior authorization requests completed in under 12 hours. “This has allowed thousands of eligible beneficiaries to access GLP-1 medications for weight loss at pharmacies nationwide,” Foster said.
Primary care physician Taylor Lacy, who practices at Sunflower Medical Group in Roeland Park, Kansas, said the Bridge program is leaving behind patients with the greatest medical need. She noted that many Medicare patients already must navigate prior authorization and step therapy — trying cheaper alternatives first — before getting approval, only to discover their GLP-1 copays run $200 to $600 a month or more.
“ ‘Coverage’ doesn’t always mean ‘affordable,’ ” Lacy said.
Researchers studying how Medicare insurers cover GLP-1s have found that recipients have faced increases in out-of-pocket costs and that almost all plans now require prior authorization. Chris Bond, a spokesperson for insurance industry trade group AHIP, blamed drugmakers’ prices, “which they alone set and they alone can lower.”
La Marca’s insurer declined to answer specific questions about his case. He continues to use a machine to treat his sleep apnea and remains without access to the discounted drug.
