Medicare’s GLP-1 discount program excluded millions of patients — Fortune
The Medicare Bridge pilot program in the United States offers some Medicare beneficiaries GLP-1 drugs for weight loss at $50 per month. At the same time, it does not apply to millions of patients with certain diagnoses for which the U.S. Food and Drug Administration has approved GLP-1 drugs. As Fortune reports, people with type 2 diabetes or moderate to severe obstructive sleep apnea are directed to their Medicare Part D plans, where copayments for these medicines can amount to hundreds of dollars per month.
Who can access the discount
The program was launched as an 18-month experiment to assess whether coverage of weight-management drugs can reduce future Medicare costs. Participation requires enrollment in a Medicare Part D plan. A prior authorization request is submitted not to the insurer, but through a separate system run by a contractor of the U.S. Centers for Medicare & Medicaid Services.
The program includes Wegovy, Zepbound in KwikPen form, and the oral drug Foundayo. Patients with a body mass index of 35 or higher are generally eligible for coverage. People with a BMI of 27 to 34 may qualify if they have certain conditions, including prediabetes or cardiovascular disease.
The $50 price applies only when the drug is prescribed exclusively for weight loss. If a patient has a diagnosis for which the FDA has approved GLP-1, they are directed to Medicare Part D on less favorable terms.
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Rejection of a patient with sleep apnea
Jeff La Marca, 68, of Basking Ridge, New Jersey, was prescribed Zepbound in January, but he could not afford to pay $750 per month. His Bridge application was denied. La Marca has severe obstructive sleep apnea, a BMI of 42, prediabetes, and has undergone quadruple heart bypass surgery. He believes that without the sleep apnea diagnosis, he could qualify for the discount because of his weight.
According to KFF estimates, about 5.9 million Medicare beneficiaries are excluded from the Bridge discounted-price program because of such diagnoses, although they may qualify for GLP-1 coverage through Part D. Juliette Cubanski, director of the Medicare policy program at KFF, estimated that 3.8 million people are eligible for Bridge. If one-quarter of them use the treatment for all 18 months, Medicare costs could amount to about $3.3 billion, while participation by three-quarters could raise them to as much as $10 billion.
High copayments under insurance plans
Timothy Foster, a spokesperson for the U.S. Centers for Medicare & Medicaid Services, said that in the first weeks of the program, most prior authorization requests were processed in less than 12 hours, and thousands of beneficiaries gained access to the drugs at pharmacies across the country.
Primary care physician Taylor Lacy noted that insurance coverage does not always mean an affordable price. According to her, Medicare patients often go through prior authorization and first try cheaper alternatives, but ultimately face copayments of $200 to $600 per month or more. Researchers have also recorded rising out-of-pocket costs for patients and that nearly all plans now require prior authorization for GLP-1 drugs.
