In January, Jeff La Marca got a prescription for the popular weight loss drug Zepbound. But he couldn’t 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.
“I thought, ‘Thank God, there’s a path,'” said La Marca, who lives in Basking Ridge, N.J., and has tried numerous diets and exercise regimes.
But the 68-year-old’s celebration was short-lived.
His application to the pilot program was denied.
La Marca has severe obstructive sleep apnea, one of several diagnoses that exclude patients from the Medicare GLP-1 Bridge program’s $50 monthly price.
The notification didn’t say why he was rejected. He thinks that if he didn’t have that diagnosis, he would qualify due to his weight.
“I’m obese, morbidly obese, BMI 42. I had quadruple heart bypass surgery. I’m at risk for stroke. I’m prediabetic. And yet I can’t get it. I’m livid,” he said.
A temporary patch for a long-standing gap
About 1 in 5 American adults has taken a GLP-1 medication, and most of them, including those with health insurance, say the drugs are difficult to afford. Federal law has long barred Medicare from covering drugs prescribed solely for weight loss, which is why the Medicare GLP-1 Bridge program made a big splash when it launched in July.
It’s a short-term pilot program in which Medicare is offering coverage of three GLP-1s for weight loss and management, to see whether 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’t go through the insurer; it’s instead submitted to a separate system run by a contractor for the Centers for Medicare & Medicaid Services.
The pilot includes Wegovy, the KwikPen formulation of Zepbound and the oral medication Foundayo.
Under the pilot, many Medicare beneficiaries with a body mass index of 35 or higher — the upper range of obesity — 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.
But buried in the fine print is a distinction that’s 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.
“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,” said Juliette Cubanski, who directs the Program on Medicare Policy at KFF, a health information nonprofit that includes KFF Health News.
)
The cost to Medicare of subsidizing the drugs will depend largely on how many people use the program, and the federal government hasn’t released an estimate.
Cubanski has estimated that 3.8 million people qualify and that, if a quarter of them enroll in Bridge and remain on treatment for the program’s full 18 months, it will cost Medicare about $3.3 billion. If three-quarters enroll, costs could rise to $10 billion.
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 of dollars more to the program’s cost.
The demonstration’s initial weeks have been positive, and most prior authorization requests have been completed in under 12 hours, CMS spokesperson Timothy Foster said.
“This has allowed thousands of eligible beneficiaries to access GLP-1 medications for weight loss at pharmacies nationwide,” Foster said.
When GLP-1s aren’t affordable
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.
“‘Coverage’ doesn’t always mean ‘affordable,'” said primary care physician Taylor Lacy, who describes herself as a “big proponent” of GLP-1s and practices at Sunflower Medical Group in Roeland Park, Kansas.
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 — 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.
)
Researchers studying how Medicare insurers cover GLP-1s have found 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.
Chris Bond, a spokesperson for insurance industry trade group AHIP blamed drugmakers’ prices, “which they alone set and they alone can lower.”
La Marca’s insurer declined to answer specific questions about La Marca’s case.
Patients and prescriptions left waiting
For now, La Marca’s 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.
As he reflected on his appeals and the dead ends, La Marca paused, his eyes filling with tears of frustration.
“This is now my quest, because it’s my only chance to improve my health,” he said. “It’s the only thing left. I’ve tried everything.”
This story comes from NPR’s health reporting partnership with KFF Health News, a national newsroom that produces in-depth journalism about health issues. KFF Health News is one of the core operating programs at KFF — the independent source for health policy research, polling and journalism.
Transcript:
AILSA CHANG, HOST:
If you’re on Medicare, it can be tricky getting coverage for the blockbuster weight loss drugs known as GLP-1s. It depends on your exact diagnosis, and you might need to pay hundreds of dollars in copays or coinsurance. Last month, Medicare launched a pilot program that could streamline that process. Some eligible seniors will pay just $50 a month for the drugs. But as Jackie Fortier with our partner KFF Health News reports, many people with the most serious illnesses still will not get that discount.
JACKIE FORTIER, BYLINE: When Jeff La Marca heard about Medicare’s new GLP-1 Bridge program, he thought he’d finally found a way to afford Zepbound. The retired professor has spent years trying to lose weight.
JEFF LA MARCA: And I said, thank God there’s a path for it.
FORTIER: Medicare’s temporary discount program applies to people who use the GLP-1 drugs for weight loss and only for weight loss. Patients who qualify pay just $50 a month. On the first day applications opened, La Marca’s doctor in New Jersey submitted the paperwork. He was denied. To him, it didn’t make any sense.
LA MARCA: I’m obese, You know, morbidly obese, BMI 42. I’m at risk for stroke. I’m prediabetic. And yet I can’t get it.
FORTIER: La Marca is among an estimated 5.9 million Medicare enrollees who were locked out of the discount program because they have medical conditions like Type 2 diabetes or sleep apnea, conditions that GLP-1s treat. The Centers for Medicare & Medicaid Services runs the GLP-1 Bridge Program. It’s a pilot that’ll run for 18 months. Spokesperson Timothy Foster says the goal is to study whether Medicare can save money by treating obese patients upfront with GLP-1s before they develop more costly chronic health conditions. But there are eligibility rules around who can be part of the pilot. People like La Marca technically do have another option – go through their Medicare Part D prescription drug plans. In practice, though…
TAYLOR LACY: Coverage doesn’t always mean paid for or affordable.
FORTIER: Taylor Lacy is a primary care physician in Kansas. She says patients often spend months jumping through insurance hoops to unlock Part D coverage, succeed and then get sticker shock.
LACY: In general, I would say my patients’ copays are anywhere from 200 to $600.
FORTIER: Which is unaffordable. Lacy worries their health will get worse if they give up on getting the medicine.
LACY: They need treatment, and those are the people that are being neglected.
FORTIER: Without the medication, Jeff La Marca worries about his heart and about having a stroke.
LA MARCA: I’m terrified. I can’t lose weight, and my sleep is horrible. My stress is beyond tolerable.
FORTIER: He eventually got his Medicare drug plan to cover Zepbound. But at the pharmacy, he found out his monthly copay would be hundreds of dollars. More than he could pay.
LA MARCA: I’ve got too much to do in my life yet, and I’d like to be healthy. I’d like to be a lot thinner. I’m tired of being fat.
FORTIER: The GLP-1 prescription he fought so hard to get approved is still too expensive for him to fill. It’s still waiting at the pharmacy.
CHANG: Jackie Fortier is a reporter with our partner KFF Health News.
