The Medicare GLP-1 discount is here, so why are some sick people excluded?

The Medicare GLP-1 discount program, launched in January, aims to make popular weight loss drug Zepbound more affordable for some Medicare enrollees, with a monthly price of only $50. However, the eligibility criteria for this pilot program have sparked controversy, with some patients excluded even though they have severe medical conditions.

Jeff La Marca, a 68-year-old resident of Basking Ridge, New Jersey, is among the estimated 5.9 million Medicare members who are excluded from the program due to a medical condition like Type 2 diabetes or sleep apnea. Despite having a BMI of 42 and having undergone quadruple heart bypass surgery, La Marca is denied the $50 monthly price for Zepbound, instead facing higher out-of-pocket costs through his Medicare Part D prescription drug plan.

The Bridge program, a 18-month pilot, aims to test if subsidizing GLP-1 medications for weight loss will save Medicare money in the long run. Eligible patients must be enrolled in Medicare Part D and have a BMI of at least 35, or a BMI of 27 to 34 with qualifying medical conditions. However, patients with conditions such as Type 2 diabetes or moderate to severe obstructive sleep apnea, which are FDA-approved for GLP-1 treatments, are instead routed back to their Part D plan, often facing higher copays.

Critics argue that the program leaves behind patients with the greatest medical need, who already face steep out-of-pocket costs and prior authorization hurdles. While the program's initial weeks have been positive, the full cost impact remains uncertain, with estimates ranging from $3.3 billion to $10 billion depending on enrollment levels.