Medicare GLP-1 discount excludes some sick patients

Medicare launched an 18-month pilot program in July offering GLP-1 medications for only $50 a month to some enrollees, but the new discount is leaving a significant portion of the population behind.

Strict Eligibility Rules Exclude the Most Vulnerable

Jeff La Marca, a 68-year-old retired professor from Basking Ridge, New Jersey, thought the program would finally make the $750 monthly price tag of Zepbound affordable. La Marca has a body mass index of 42 and a history of heart surgery. The retired professor received a denial notice for the pilot program. The rejection was based on his diagnosis of severe obstructive sleep apnea, a medical condition that automatically disqualifies him from the $50 monthly rate.

La Marca said he is “livid” about the denial. He has tried numerous diets and exercise regimes without success, and he believes his other health risks, including prediabetes, should qualify him for the drug. He is not alone in this frustration. An estimated 5.9 million Medicare enrollees are excluded from the Bridge program because they have medical conditions like Type 2 diabetes or sleep apnea.

The pilot includes Wegovy, the KwikPen formulation of Zepbound, and the oral medication Mounjaro. Eligibility is based on a body mass index of 35 or higher, or a BMI of 27 to 34 combined with specific health conditions. However, the program covers the drugs only for weight loss. If a patient has a qualifying medical condition for which the FDA has approved the medication, the patient is routed back to their Medicare Part D plan, which can require copays of hundreds of dollars a month.

“Coverage doesn’t always mean ‘affordable,'” said primary care physician Taylor Lacy, who practices in Kansas. Lacy noted that patients often face complex prior authorization and step therapy requirements before finally getting approval, only to face high out-of-pocket costs at the pharmacy counter.

The High Cost of a Temporary Fix

The program is designed to test whether subsidizing these drugs will save Medicare money in the long run. Federal law has long barred Medicare from covering weight loss drugs, so the pilot is a short-term measure to evaluate the financial impact. Federal officials have not released an estimate of the program’s total cost, though one analysis suggests it could reach $10 billion if three-quarters of eligible beneficiaries enroll.

Initial weeks of the program have been positive, with most prior authorization requests processed in under 12 hours. A spokesperson for the Centers for Medicare & Medicaid Services stated that the program has allowed thousands of eligible beneficiaries to access the medications nationwide. However, the focus on weight loss eligibility creates a difficult situation for those with the highest medical needs. La Marca’s severe sleep apnea diagnosis, which helps establish his medical need, is also what excludes him from the discount program that would bring the cost within his reach. As he reflects on his appeals and the dead ends, La Marca paused, his eyes filling with tears of frustration.

La Marca said, “This is now my quest, because it’s my only chance to improve my health. It’s the only thing left. I’ve tried everything.” His insurer declined to answer specific questions about his case, and for now, his prescription remains unfilled.