In January, Jeff La Marca got a prescription for the popular weight loss drug Zepbound. But he couldn\u2019t afford the $750 monthly price tag.<\/p>\n
Then Medicare launched an 18-month pilot program that offers GLP-1 medications to some enrollees for only $50 a month. La Marca thought he might finally be able to afford the drug.<\/p>\n
\u201cI thought, \u2018Thank God, there\u2019s a path,\u2019\u201d said La Marca, who lives in Basking Ridge, New Jersey, and has tried numerous diets and exercise regimes.<\/p>\n
But the 68-year-old\u2019s celebration was short-lived.<\/p>\n
His application to the pilot program was denied.<\/p>\n
La Marca has severe obstructive sleep apnea, one of several diagnoses that exclude patients from the Bridge program\u2019s $50 monthly price. The notification didn\u2019t say why he was rejected. He thinks that if he didn\u2019t have that diagnosis, he would qualify due to his weight.<\/p>\n
\u201cI\u2019m obese, morbidly obese, BMI 42. I had quadruple heart bypass surgery. I\u2019m at risk for stroke. I\u2019m prediabetic. And yet I can\u2019t get it. I\u2019m livid,\u201d he said.<\/p>\n
\t\t\t\t\t<\/p>\n
\t\t\t\t\t\t\tJeff La Marca uses a machine to treat his obstructive sleep apnea. It adjusts his breathing with every breath.\t\t\t\t\t\t (Erica S. Lee for KFF Health News)<\/p>\n
\t\t\t\t\t<\/p>\n
\t\t\t\t\t\t\tLa Marca, a retired professor living in Basking Ridge, New Jersey, is among an estimated 5.9 million Medicare enrollees excluded from a GLP-1 discount program because they have a medical condition such as Type 2 diabetes or sleep apnea.\t\t\t\t\t\t (Erica S. Lee for KFF Health News)<\/p><\/div>\n<\/div>\n
A Temporary Patch for a Long-Standing Gap<\/strong><\/strong><\/p>\n About 1 in 5 American adults have taken a GLP-1 medication, and most of them, including those with health insurance, say the drugs are difficult to afford<\/a>. Federal law has long barred Medicare from covering drugs prescribed solely for weight loss, which is why the Medicare GLP-1 Bridge program<\/a> made a big splash when it launched in July.<\/p>\n It\u2019s a short-term pilot program in which Medicare is offering coverage of three GLP-1s for weight loss and management, to see if that would save Medicare money later. Eligible patients must be enrolled in Medicare Part D, a prescription drug coverage add-on to Medicare. Even though people must have Part D insurance to qualify, the preauthorization request doesn\u2019t go through the insurer; it\u2019s instead submitted to a separate system run by a contractor for the Centers for Medicare & Medicaid Services.<\/p>\n The pilot includes Wegovy, the KwikPen formulation of Zepbound, and the oral medication Foundayo.<\/p>\n Under the pilot, many Medicare beneficiaries with a body mass index of 35 or higher \u2014 the upper range of obesity<\/a> \u2014 qualify for coverage of one of those drugs, if prescribed. Those otherwise eligible who have a BMI of 27 to 34 can qualify if they also have certain health conditions, such as prediabetes or cardiovascular disease.<\/p>\n But buried in the fine print is a distinction that\u2019s tripping up patients like La Marca: The $50 price under Bridge applies only to people using the drug solely for weight loss. Anyone who has 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 instead routed back to their Medicare Part D prescription drug plan, which can require copays of hundreds of dollars a month for GLP-1s.<\/p>\n \u201cThe Bridge program was designed to target those people who can\u2019t get GLP-1 coverage through Part D but would benefit from taking one for weight loss,\u201d said Juliette Cubanski, who directs the Program on Medicare Policy at KFF, a health information nonprofit that includes KFF Health News.<\/p>\n The cost to Medicare of subsidizing the drugs will depend largely on how many people use the program, and the federal government hasn\u2019t released an estimate.<\/p>\n Cubanski has estimated<\/a> that 3.8 million people qualify and that, if a quarter of them enroll in Bridge and remain on treatment for the program\u2019s full 18 months, it will cost Medicare about $3.3 billion. If three-quarters enroll, costs could rise to $10 billion.<\/p>\n If the government expanded the program to include the additional 5.9 million people who are overweight and already eligible for GLP-1 coverage through Medicare Part D, it would add billions more to the program\u2019s cost.<\/p>\n The demonstration\u2019s initial weeks have been positive, and most prior authorization requests have been completed in under 12 hours, CMS spokesperson Timothy Foster said.<\/p>\n \u201cThis has allowed thousands of eligible beneficiaries to access GLP-1 medications for weight loss at pharmacies nationwide,\u201d Foster said.<\/p>\n \u201cI\u2019m obese, morbidly obese, BMI 42. I had quadruple heart bypass surgery. I\u2019m at risk for stroke. I\u2019m prediabetic. And yet I can\u2019t get it. I\u2019m livid,\u201d La Marca says, referring to the popular weight loss drug Zepbound. (Erica S. Lee for KFF Health News)<\/p>\n GLP-1s Aren\u2019t Covered<\/strong><\/p>\n Patients like La Marca are left in a tough spot, qualifying for Part D coverage of a GLP-1 but facing much higher cost sharing.<\/p>\n \u201c\u2018Coverage\u2019 doesn\u2019t always mean \u2018affordable,\u2019\u201d said primary care physician Taylor Lacy<\/a>, who describes herself as a \u201cbig proponent\u201d of GLP-1s and practices at Sunflower Medical Group in Roeland Park, Kansas.<\/p>\n The Bridge program is leaving behind patients with the greatest medical need, she said. She noted that many Medicare patients already must navigate prior authorization and spend months trying alternate, often cheaper treatments, a process known as step therapy, before finally getting approval \u2014 only to arrive at the pharmacy counter and discover that their GLP-1 copays will run them $200 to $600 a month, if not more.<\/p>\n Researchers studying how Medicare insurers cover GLP-1s have found<\/a> that recipients have faced increases in out-of-pocket costs and that almost all plans now require prior authorization, which can make getting the drugs more difficult.<\/p>\n Chris Bond, a spokesperson for insurance industry trade group AHIP, blamed drugmakers\u2019 prices, \u201cwhich they alone set and they alone can lower.\u201d<\/p>\n La Marca\u2019s insurer declined to answer specific questions about La Marca\u2019s case.<\/p>\n Left Waiting<\/strong><\/p>\n For now, La Marca\u2019s GLP-1 prescription remains unfilled. The severe sleep apnea diagnosis that helps establish his medical need is also what excludes him from the discount program that would bring the cost within his reach.<\/p>\n As he reflected on his appeals and the dead ends, La Marca paused, his eyes filling with tears of frustration.<\/p>\n \u201cThis is now my quest, because it\u2019s my only chance to improve my health,\u201d he said. \u201cIt\u2019s the only thing left. I\u2019ve tried everything.\u201d<\/p>\n<\/div>\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/em><\/p>\n This article<\/a> first appeared on KFF Health News<\/a> and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License<\/a>.<\/p>","protected":false},"excerpt":{"rendered":" In January, Jeff La Marca got a prescription for the popular weight loss drug Zepbound. But he couldn\u2019t afford the $750 monthly price tag. Then Medicare launched an 18-month pilot program that offers GLP-1 medications to some enrollees for only $50 a month. La Marca thought he might finally be able to afford the drug….<\/p>\n","protected":false},"author":0,"featured_media":15240,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[],"class_list":["post-15239","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-articles"],"_links":{"self":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/15239"}],"collection":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"replies":[{"embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=15239"}],"version-history":[{"count":0,"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/15239\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/media\/15240"}],"wp:attachment":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=15239"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=15239"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=15239"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}