The Centers for Medicare and Medicaid Services (CMS) is expanding access to GLP-1 medications for obesity treatment through a new temporary pilot program. However, concerns arise regarding whether the agency is prepared to handle the influx of beneficiaries who may seek these effective weight-loss drugs.
Historically, access to GLP-1 medications for weight loss has been a challenge for older adults, as Medicare typically does not cover drugs for this purpose. The recently launched Medicare GLP-1 Bridge Program allows CMS to bypass this statutory restriction by utilizing federal demonstration authority, which empowers the Department of Health and Human Services (HHS) secretary to test new Medicare and Medicaid payment methodologies. As of March 2024, CMS established coverage for Wegovy concerning cardiovascular indications, but not specifically for weight loss. Prior to this, coverage was limited to diabetic patients.
Under the Medicare GLP-1 Bridge program, eligible Medicare Part D beneficiaries can access GLP-1 medications for weight loss at a cost of $50 per month. This pilot program is set to run until December 31, 2027, and is expected to benefit nearly 40% of adults aged 60 and older who are struggling with obesity.
“For too long, many Americans have been unable to access these treatments due to their cost,” stated Dr. Mehmet Oz, CMS administrator, in a recent statement. “The Medicare GLP-1 Bridge creates a new pathway for eligible beneficiaries to obtain GLP-1 medications.”
Despite the potential for increased access, pharmacy experts warn that the expanded coverage might inadvertently impose significant financial burdens on the Medicare system. Dared Price, president of Price Pharmacies Inc., expressed concerns about the underestimation of demand for GLP-1 medications for weight loss. “Most employers have opted not to cover weight-loss costs, fearing financial repercussions due to the enormous impact these medications can have on health outcomes,” he noted.
According to recent KFF analysis, roughly 3.8 million Medicare beneficiaries may qualify for the Bridge program based on 2023 claims data. Under this initiative, manufacturers will provide eligible GLP-1 medications at a net cost of $245 per monthly supply, potentially costing CMS approximately $741 million per month if all eligible beneficiaries enroll, after accounting for the $50 monthly beneficiary co-payment.
A recent survey by the International Foundation of Employee Benefit Plans showed that only 36% of employers currently cover GLP-1 medications for both diabetes and weight loss, while 60% limit coverage to diabetes treatment. Adding to the complexity, Cigna recently made headlines for dropping coverage for GLP-1 drugs among its own employees.
Furthermore, financial coverage for weight-loss medications is waning, with insurers like Blue Cross Blue Shield of Massachusetts and Harvard Pilgrim Health Care, as well as Medicaid programs in California, Pennsylvania, and South Carolina retracting their support.
Concerns from Healthcare Experts
Price shared further worries about the disparities in pricing for GLP-1 medications, highlighting that Medicare patients diagnosed with obesity could pay $50, while those prescribed similar drugs for diabetes may be liable for much higher costs due to plan design inconsistencies. Such disparities could force diabetes patients to pay hundreds of dollars out-of-pocket due to deductible requirements.
In addition, Price raised concerns regarding supply chain impacts, particularly given existing shortages of GLP-1 medications. An influx of new patients may exacerbate these challenges, leading to broader access issues.
Pharmacies involved in the Bridge program are also navigating operational hurdles. When prescriptions are electronically transmitted, there may be uncertainty regarding a patient’s eligibility for the Bridge program, complicating the dispensing process. “These authorizations represent extra paperwork and delays for the patient if the prescription is initially submitted to the wrong program,” Price explained.
Despite these challenges, Price indicated that his pharmacy continues to participate in the program. However, the high cost of these medications remains a barrier for many pharmacies.
Concerns about potential misuse of GLP-1 medications have also been raised. Sandeep Palakodeti, chief medical officer at Bold, emphasized the importance of appropriate support alongside medication to ensure safe usage. Bold has incorporated GLP-1 prescriptions into its weight management program to provide monthly consultations, strength training, and nutritional support.
Another healthcare advocate remarked that while the program signifies a crucial step towards broader access, it falls short of addressing the chronic nature of obesity. “Medicare, Medicaid, and employer-sponsored plans need to cover a comprehensive range of evidence-based obesity care including FDA-approved medications, intensive behavioral therapy, nutritional counseling, physical activity, and bariatric surgery,” stated Millicent Gorham, CEO of the Alliance for Women’s Health and Prevention.
The hope is that the Biden administration may eventually extend Medicare coverage for GLP-1 medications through regulatory updates or congressional approval of the Treat and Reduce Obesity Act, sponsored by Senator Bill Cassidy (R-LA).
As access to transformative medications evolves, the potential financial ramifications for CMS remain uncertain and could influence future policy decisions regarding obesity treatment coverage.
Photo: Jason Dean, Getty Images
