Medicare's $50 GLP-1 Discount Excludes Patients With Certain
A new Medicare pilot program offers GLP-1 weight-loss drugs for $50 a month, but patients with FDA-approved conditions like sleep apnea are excluded
Jeff La Marca, 68, was denied access to a $50 monthly Medicare discount for the weight-loss drug tirzepatide. His severe obstructive sleep apnea diagnosis excluded him from the program, leaving him unable to afford the $750 monthly price.
About one in five American adults have taken a GLP-1 medication, and most find them difficult to afford. Federal law has long barred Medicare from covering drugs prescribed solely for weight loss. The Medicare GLP-1 Bridge program, launched in July, is an 18-month pilot testing coverage of three GLP-1s for weight management to see if it saves money later.
How The Bridge Program Works
Eligible patients must be enrolled in Medicare Part D. The pilot includes semaglutide (Wegovy), the KwikPen formulation of tirzepatide, and the oral medication orforglipron (Foundayo). Many beneficiaries with a body mass index (BMI) of 35 or higher qualify. Those with a BMI between 27 and 34 can qualify if they also have certain conditions like prediabetes or cardiovascular disease.
Juliette Cubanski, PhD, MPH, who directs the Program on Medicare Policy at KFF, explained the design. "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," she said.
The Big Catch For Sick Patients
The $50 price applies only to people using a GLP-1 solely for weight loss. Patients with a qualifying medical condition that the FDA has approved GLP-1s to treat, such as type 2 diabetes or moderate to severe obstructive sleep apnea, are routed back to their Part D plan. Those plans can require copays of hundreds of dollars a month.
La Marca, who lives in Basking Ridge, New Jersey, has a BMI of 42 and a history of quadruple heart bypass surgery. He is prediabetic and at risk for stroke. "I'm livid," he said. His application denial did not specify a reason, but he believes his sleep apnea diagnosis is the barrier.
Cost Estimates And Program Impact
Cubanski has estimated that 3.8 million people qualify for the Bridge program. If a quarter of them enroll for the full 18 months, it would cost Medicare about $3.3 billion. If three-quarters enroll, costs could rise to $10 billion. Including the 5.9 million people who are overweight and already eligible for GLP-1 coverage through Part D would add billions more.
A CMS spokesperson, Timothy Build, said the demonstration's initial weeks have been positive. Most prior authorization requests are completed in under 12 hours. "This has allowed thousands of eligible beneficiaries to access GLP-1 medications for weight loss at pharmacies nationwide," Build said.
When Coverage Isn't Affordable
Primary care physician Taylor Lacy, MD, a proponent of GLP-1s, said the program leaves behind patients with the greatest medical need. She noted many patients handle prior authorization and step therapy only to find copays of $200 to $600 a month at the pharmacy. Researchers have found that Medicare recipients face increases in out-of-pocket costs for these drugs, with almost all plans requiring prior authorization.
Insurance industry trade group AHIP spokesperson Chris Bond blamed drugmakers' prices, "which they alone set and they alone can lower." La Marca's insurer declined to answer questions about his case.
For now, Jeff La Marca's prescription remains unfilled. "This is now my quest, because it's my only chance to improve my health," he said, his eyes filling with tears of frustration. "It's the only thing left. I've tried everything."
