Medicare's $50 GLP-1 pilot leaves some high-risk patients without coverage
The Medicare GLP-1 Bridge pilot caps the price of three weight-loss drugs at $50 a month, but patients with certain medical conditions, like obstructive sleep apnea, are excluded and must pay much higher copays.
Medicare has begun an 18-month demonstration called the GLP-1 Bridge program, subsidizing Wegovy, Zepbound’s KwikPen and the oral drug Foundayo at $50 a month for eligible beneficiaries. To qualify, participants must be enrolled in Medicare Part D and have a BMI of 35 or higher, or a BMI of 27-34 with certain health issues; however, the discounted price applies only when the medication is prescribed solely for weight loss.
Patients who have a condition for which the FDA approves GLP-1 therapy, such as Type 2 diabetes or moderate to severe obstructive sleep apnea, must use their Part D plan and often face copays of several hundred dollars. Jeff La Marca, a 68-year-old resident of Basking Ridge, N.J., was rejected because of his severe obstructive sleep apnea, leaving his prescription unfilled despite his obesity, pre-diabetes and prior heart surgery.
Program officials say the initiative is meant for those unable to secure Part D coverage, and most prior-authorization requests are completed within 12 hours, but analysts estimate total program costs could range from $3.3 billion to $10 billion. Critics, including primary-care physician Taylor Lacy, warn the design excludes patients with the greatest medical need, underscoring broader affordability challenges for Medicare beneficiaries.
Why it matters
The story highlights how Medicare's new drug discount plan may still leave high-risk patients unable to afford essential weight-loss medicines.
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