New Medicare Drug Access
Medicare Launches Pilot Program July 1 to Cover Weight-Loss Drugs for Millions
Starting July 1, millions of senior Americans will get weight-loss drug coverage through Medicare for the very first time. The new pilot program, called the **Medicare GLP-1 Bridge**, gives eligible enrollees access to blockbuster drugs like Wegovy and Zepbound for a flat $50 monthly copay — down from retail prices of $1,000 or more, according to CMS.
The 18-month program is a landmark shift. Since 2003, federal law has banned Medicare from covering weight-loss drugs. The Trump administration used a legal workaround — called Section 402 demonstration authority — to launch the program without waiting for Congress to act, KFF reported.
How the $50 Copay Deal With Drug Makers Works
The government struck deals with Eli Lilly and Novo Nordisk to slash the cost of their drugs. The negotiated price is about $245 per month — an 82% to 96% discount from the standard retail price, according to AmeriLife. Medicare passes most of those savings to patients, who pay just $50 out of pocket.
Three drugs are covered under the program: Wegovy (semaglutide), Zepbound (tirzepatide) via KwikPen only, and a new daily pill called Foundayo (orforglipron) from Eli Lilly, per CMS. Vials of Zepbound are excluded. The program runs through December 31, 2027.
Who Qualifies — and Who Gets Left Out
Not every Medicare enrollee can join. To qualify, a patient must be enrolled in Medicare Part D and meet specific body and health criteria. People with a BMI of 35 or higher qualify automatically. Those with a BMI between 30 and 34.9 must also have a condition like high blood pressure, chronic kidney disease, or heart failure, according to CMS.
There is one notable exclusion. Patients who already have Type 2 diabetes must use their standard Part D drug plan instead of the Bridge program, UPMC Health Plan noted. Market analysts at Evercore ISI estimate roughly 3 million Medicare enrollees will qualify immediately, according to Seeking Alpha.
Dr. Oz Celebrates Access, Critics Warn of a Coverage Cliff
CMS Administrator Dr. Mehmet Oz called the launch a win for seniors. "These treatments are a major medical advancement, but too many seniors are currently unable to access them due to high cost," Oz said, per the Washington Post. "The Medicare GLP-1 Bridge changes that."
But critics are less enthusiastic. KFF's Juliette Cubanski warned: "It is a temporary program. It is not a permanent change." Some health advocates have called it a "Bridge to Nowhere" — arguing that seniors who stop taking GLP-1 drugs quickly regain weight, leaving them worse off when the program ends in 2028, the Washington Post reported.
Pharmacies Brace for a Rocky First Week
The Bridge program runs outside the normal Medicare Part D claims system. CMS is using a "single central processor" to handle prescriptions instead. Pharmacy Times warned that pharmacy teams may face major technical hurdles filling claims during the first days of the rollout.
Providers were told to submit prior authorizations before July 1 to avoid delays at the pharmacy counter, according to the AMA. If the program works as planned, the Congressional Budget Office projects it could save the healthcare system $3.4 billion by 2034 by cutting heart attacks and diabetes complications, per AmeriLife.
Sentiment
NeutralPublishers
6
Articles
6
Reach
6
