Medicare $50 GLP-1 Bridge excludes patients already covered for diabetes or sleep apnea

WASHINGTON - Medicare's GLP-1 Bridge pilot can drop the monthly cost of some weight-loss drugs to $50 for certain Part D enrollees, NPR and KFF Health News reported. The catch is that many of the sickest patients do not get that price.

Federal law still bars Medicare from covering drugs prescribed solely for weight loss. The 18-month Bridge demonstration, which began in July, is a limited test of covering Wegovy, a KwikPen form of Zepbound, and the oral drug Foundayo for weight management. Eligible people must have Medicare Part D.

Patients with a body mass index of 35 or higher often qualify. Those with a BMI of 27 to 34 can qualify if they also have listed conditions such as prediabetes or cardiovascular disease. Prior authorization for Bridge runs through a CMS contractor, not the Part D insurer, and CMS said many requests are finished in under 12 hours.

The fine print steers a different group away from the $50 price. If the Food and Drug Administration has already approved a GLP-1 for a patient's condition, such as Type 2 diabetes or moderate to severe obstructive sleep apnea, the person is sent back to regular Part D coverage. That path can mean copays of hundreds of dollars a month.

Jeff La Marca, 68, of Basking Ridge, N.J., told NPR he has a BMI of 42, prior heart bypass surgery and prediabetes, yet was denied Bridge because of severe sleep apnea. Primary care physician Taylor Lacy of Roeland Park, Kansas, said the design can leave patients with the greatest medical need paying more.

KFF's Juliette Cubanski estimated about 3.8 million people may qualify for Bridge. If a quarter stay on treatment for the full 18 months, Medicare costs could reach about $3.3 billion; higher uptake would cost more. CMS said thousands of eligible beneficiaries have already filled Bridge prescriptions.

Drugstores report the pilot is catching on among patients who clear the rules. For everyone else, "coverage" still does not mean "affordable." Seniors should ask whether their case is Bridge or standard Part D before counting on a $50 refill.