| The skinny
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? The Medicare GLP-1 Bridge program
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.” Does CMS know what it is doing?
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. — By Marissa Plescia |
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