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Medicare GLP-1 Bridge excludes sicker patients from the $50 copay
The $50 monthly copay applies only to enrollees using GLP-1s for weight loss without certain qualifying diagnoses, routing people with conditions such as Type 2 diabetes back to standard Part D where copays often run $200 to $600 or more.
Medicare’s GLP-1 Bridge program, launched in July, offers some seniors select GLP-1 weight-loss drugs for a $50 monthly copay, but it excludes people with the most serious qualifying conditions, according to KFF Health News.
The program, run by the Centers for Medicare and Medicaid Services, covers Wegovy, a KwikPen formulation of Zepbound, and oral Foundayo for eligible Medicare Part D enrollees through December 31, 2027. Because it operates outside the standard Part D benefit, Part D plans do not need to opt in and do not carry the drug costs, and CMS is using demonstration data to evaluate whether GLP-1 access reduces downstream Medicare costs.
The Bridge is designed to comply with federal limits that bar Medicare from covering drugs prescribed solely for weight loss. Under the program’s eligibility rules, enrollees with diagnoses including Type 2 diabetes, moderate to severe obstructive sleep apnea, or metabolic dysfunction-associated steatohepatitis are sent back to their standard Part D plan, where GLP-1 copays typically run $200 to $600 a month or more.
KFF estimates that 3.8 million Medicare Part D enrollees met Bridge eligibility criteria based on 2023 claims data, out of 9.7 million who met the clinical criteria for obesity or overweight. With 25% participation, KFF estimates the cost to Medicare could reach about $3.3 billion, and CMS said most prior authorization requests are being processed in under 12 hours.