Medicare GLP-1 Bridge Excludes Sleep Apnea Patients
Jeff La Marca, 68, of Basking Ridge, NJ, was denied Medicare’s $50-per-month GLP-1 Bridge program because of severe obstructive sleep apnea, despite qualifying for the drug. The pilot, launched July, offers three weight-loss GLP-1s to eligible beneficiaries for 18 months.
Jeff La Marca, 68, lives in Basking Ridge, New Jersey, and in January received a prescription for the weight-loss drug Zepbound. The drug costs $750 a month, a price he could not afford. Medicare’s 18-month Bridge pilot promised the same medication for only $50 a month, and La Marca applied.
His application was denied. The notification did not explain the reason, but La Marca believes the denial stems from his diagnosis of severe obstructive sleep apnea, a condition that excludes patients from the Bridge discount.
Bridge Program Overview
The pilot covers three GLP-1 medications-Wegovy, the KwikPen formulation of Zepbound, and the oral drug Foundayo-for weight loss and management. Eligibility is based on body-mass index (BMI) and medical conditions.
| BMI Range | Additional Conditions Required | Covered Medication | Discount |
|---|---|---|---|
| 35 or higher | None | Any of the three GLP-1s | $50/month |
| 27-34 | Prediabetes or cardiovascular disease | Any of the three GLP-1s | $50/month |
Patients with a qualifying medical condition approved by the FDA for GLP-1 use-such as type 2 diabetes or moderate-to-severe obstructive sleep apnea-are routed to their Medicare Part D plan, where copays can reach hundreds of dollars a month.
Cost Implications
KFF Health News estimates that 3.8 million people qualify for the Bridge program. If 25 % enroll and stay on treatment for the full 18 months, Medicare would spend about $3.3 billion. If 75 % enroll, costs could rise to $10 billion. Expanding the program to include an additional 5.9 million people already eligible for Part D coverage would add billions more.
| Enrollment % | Estimated Cost |
|---|---|
| 25 % | $3.3 billion |
| 75 % | $10 billion |
The Centers for Medicare & Medicaid Services (CMS) reports that most prior-authorization requests are completed in under 12 hours, allowing thousands of beneficiaries to access GLP-1s nationwide.
Patient Impact
Primary-care physician Taylor Lacy, a proponent of GLP-1s, notes that the Bridge program leaves behind patients with the greatest medical need. Many Medicare patients already navigate prior authorization and step therapy before finally receiving approval, only to find copays of $200-$600 a month.
Researchers have found that recipients of GLP-1s face increased out-of-pocket costs and that almost all plans now require prior authorization. Insurance trade group AHIP’s spokesperson Chris Bond attributes the difficulty to drugmakers’ prices.
La Marca’s insurer declined to answer specific questions about his case. For now, his prescription remains unfilled. The severe sleep-apnea diagnosis that establishes his medical need also excludes him from the discount program that would bring the cost within his reach. He says, “This is now my quest, because it’s my only chance to improve my health. It’s the only thing left. I’ve tried everything.”
