CMS is finally beginning to expand access to GLP-1s for obesity through a new, temporary pilot program. However, is it ready for the millions of beneficiaries that will potentially flood in to receive these highly effective weight loss drugs?
Accessing GLP-1 drugs for weight loss has historically been a challenge for seniors because Medicare is generally prohibited by law from covering the drugs for that indication. However, the Medicare GLP-1 Bridge program, which launched last week, allows CMS to bypass that statutory prohibition by using the federal government’s Section 402 demonstration authority, which gives the HHS Secretary the authority to test new Medicare and Medicaid payment and reimbursement methodologies. It’s important to note that in March 2024, CMS allowed Wegovy to be covered for cardiovascular indication, but not for weight loss alone. Before that, CMS covered these drugs for patients with diabetes.
The Medicare GLP-1 Bridge program allows eligible Medicare Part D beneficiaries to access GLP-1 medications for weight loss at $50 per month. The pilot will last through December 31, 2027. It comes as approximately 40% of adults aged 60 or older battle obesity.
“For too long, many Americans have been unable to access these treatments because of cost,” said CMS Administrator Dr. Mehmet Oz in a statement. “The Medicare GLP-1 Bridge creates a new pathway for eligible beneficiaries to afford GLP-1 medications.”
However, one pharmacy expert believes that while expanding coverage of GLP-1s for weight loss will have a meaningful impact on access, it could also have serious financial consequences on the Medicare system.
“I don’t know that [CMS realizes] how many people are getting GLP-1s today for weight loss. I think they’ve underestimated what that looks like. … Most employers have decided not to cover those for weight loss, because it may put them out of business financially, because of the huge impact that these things have on a bottom line, so I’m a little bit worried about the financial impact for our government, and what that means,” said Dared Price, president of Price Pharmacies Inc. “How much is that going to drive up the cost of the Medicare system?”
About 3.8 million Medicare beneficiaries may be eligible for the Bridge program based on 2023 claims data, according to a recent KFF analysis. Under the program, manufacturers will provide eligible GLP-1 drugs at a net price of $245 per monthly supply, CMS stated. If all eligible beneficiaries enroll in the program, the program would cost CMS an estimated $741 million per month after the $50 monthly beneficiary copay.
A recent survey from the International Foundation of Employee Benefit Plans found that just 36% of employers are covering GLP-1s for both diabetes and weight loss, while 60% are covering them for only diabetes. Cigna recently made headlines for dropping coverage for their own employees.
Payers have also pulled back on coverage for weight loss, including Blue Cross Blue Shield of Massachusetts and Harvard Pilgrim Health Care, as well as state Medicaid programs in California, Pennsylvania and South Carolina.
Health experts’ concerns
The potential cost of the Bridge program isn’t Price’s only concern. For example, Medicare patients may be able to access GLP-1s for $50 for obesity, but may receive a completely different price for the same drug if they have been prescribed it for controlling their diabetes through their regular Part D program. Medicare patients using GLP-1s for diabetes will likely have to meet their deductible, meaning they could be paying several hundred dollars for their medication.
Price is also worried about the impact this program could have on the supply chain, noting that there was recently a shortage of GLP-1s. If thousands more start taking these drugs, that could worsen supply chain issues.
Additionally, there are operational challenges for pharmacies with the Bridge program. When a prescription is electronically sent, the pharmacy may not know if the patient qualifies for the Bridge program, or if the prescriber intended for it to go through the Part D plan. Before Bridge, the GLP-1 prescription for obesity would be rejected by Part D and the pharmacy would send a prior authorization to the prescriber, Price said.
“However, if the pharmacy is made aware that this is intended for the Bridge program, we are able to skip that step and move straight to sending to Bridge (which also requires a prior auth),” he said. “These authorizations are extra paperwork for the provider and take between two to seven days so there is a delay for the patient if the PA is sent to the wrong program first and comes back denied. These operational challenges are already happening but many providers are already good about letting the pharmacy know which plan they think the patient will qualify for.”
Price noted that despite these challenges, his company is still participating in the program, but some pharmacies are having challenges purchasing these medications due to their high cost.
Price isn’t the only one with reservations. One medical expert believes the Bridge program is a “bold” and “compassionate” move, but is worried about the potential misuse of GLP-1s. People who don’t pair GLP-1s with the right wraparound support could lose a lot of muscle mass, which may increase fall risks, noted Sandeep Palakodeti, chief medical officer of Bold, an AI-enabled healthy aging platform.
That’s why, as part of the Bridge program, Bold launched the capability to include GLP-1 prescriptions in its weight management program. Through this program, members have monthly check-ins with their providers, and they can access strength programs and nutrition support.
“What we do not believe is that one should fill out a five minute survey, be prescribed a life-altering medication that has side effects, and adverse outcomes as well, and just check in with the practitioner every six months or so. We think that that’s the wrong way to use these medications. … So we want to make sure that individuals are engaging in the kinds of things that they need,” Palakodeti said.
Another healthcare advocate said the program is a positive step in terms of expanding access and a signal that policymakers are starting to recognize that obesity is a complex chronic disease. However, temporary access isn’t enough for a chronic disease that requires long-term treatment, she said.
“We need Medicare, Medicaid, and employer-sponsored plans to cover the full range of evidence-based obesity care, including FDA-approved medications, intensive behavioral therapy, nutrition support, physical activity and bariatric surgery, so people can work with their healthcare provider to choose the approach that is right for them,” said Millicent Gorham, CEO of the Alliance for Women’s Health and Prevention.
She noted that the Trump administration can expand Medicare coverage of GLP-1s through rulemaking, or Congress can pass the Treat and Reduce Obesity Act. This bill is sponsored by Sen. Bill Cassidy (R-Louisiana).
Expanding access to a life-altering medication is great, but will it potentially break the CMS bank? Only time will tell.
Photo: Jason Dean, Getty Images
