Medicare GLP-1 Bridge Excludes 5.9 Million From $50 Discount as Diagnoses Trigger Higher Part D Copays
Updated
Updated · Medical Daily · Aug 26
Medicare GLP-1 Bridge Excludes 5.9 Million From $50 Discount as Diagnoses Trigger Higher Part D Copays
3 articles · Updated · Medical Daily · Aug 26
Summary
An estimated 5.9 million Medicare beneficiaries are shut out of the GLP-1 Bridge’s $50 monthly price if they also have FDA-approved conditions such as type 2 diabetes or severe sleep apnea.
The exclusion stems from the pilot’s design: the discount applies only when a GLP-1 is prescribed solely for weight loss, while anyone with an approved diagnosis is sent back to Part D plans where copays often run $200 to $600 or more.
Jeff La Marca, a 68-year-old New Jersey retiree with a BMI of 42, said he was denied the Bridge price for Zepbound and faced roughly $750 a month; KFF says about 3.8 million beneficiaries do qualify.
CMS said most prior-authorization requests are completed in under 12 hours and thousands have received drugs through the 18-month pilot, but KFF estimates costs could reach $3.3 billion if a quarter of eligible patients enroll and $10 billion if three quarters do.
The finding sharpens uncertainty around Medicare’s temporary July-launched workaround for weight-loss drugs, with permanent coverage still requiring congressional action before the pilot expires.