Medicare launched an 18-month pilot program in July offering three GLP-1 medications—Wegovy, a KwikPen formulation of Zepbound, and oral Foundayo—at $50 monthly to eligible beneficiaries. The program targets Medicare Part D enrollees with a body mass index of 35 or higher, as well as those with BMI between 27 and 34 who have certain health conditions like prediabetes or cardiovascular disease.
However, the program contains a significant limitation: patients using GLP-1s to treat FDA-approved medical conditions such as Type 2 diabetes or moderate to severe obstructive sleep apnea are routed back to their standard Medicare Part D plans rather than receiving the discounted $50 price. This requirement stems from federal law that has long prohibited Medicare from covering drugs prescribed solely for weight loss. As a result, these patients may face copays ranging from hundreds to more than $600 monthly through their regular prescription drug coverage.
The exclusion creates a paradox for patients with multiple health needs. One 68-year-old applicant with obesity, prior heart bypass surgery, prediabetes, and severe obstructive sleep apnea was denied Bridge program enrollment because his sleep apnea diagnosis—which qualified him medically for the drug—made him ineligible for the discount. He initially could not afford the $750 monthly price without assistance.
Estimates suggest the program could affect millions of beneficiaries. Analysts project that 3.8 million people qualify for the pilot, with potential costs to Medicare ranging from $3.3 billion to $10 billion depending on enrollment rates. An additional 5.9 million overweight individuals already eligible for GLP-1 coverage through Part D could theoretically be added, further increasing expenses. CMS reported that initial authorization requests have been processed in under 12 hours, enabling thousands to access the medications.
Clinicians and patient advocates have expressed concern that the program’s structure leaves behind those with the greatest medical need, forcing them to navigate prior authorization requirements and step therapy protocols before facing substantial out-of-pocket expenses at the pharmacy counter.
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