'I'm livid': Medicare plan refuses to cover New Jersey man’s $750 obesity drug because it would help his sleep apnea

“I’m obese, morbidly obese, BMI 42. I had quadruple heart bypass surgery. I’m at risk for stroke. I’m prediabetic,” he said. “And yet I can’t get it. I’m livid.”

On top of all those conditions, La Marca has severe obstructive sleep apnea — one of the conditions that prompted his doctor to give him a prescription for the GLP-1 drug Zepbound, FDA-approved for the treatment of sleep apnea.

But even though he got the prescription earlier this year, La Marca never got it filled out because he can’t afford the $750 a month cost.

That’s why he was holding out hope for Medicare’s Bridge pilot program, which launched in July and runs through the end of 2027. It covers the weight-loss drugs Zepbound and Foundayo (both Eli Lilly and Company drugs) and Novo Nordisk’s Wegovy.

“I thought, ‘Thank God, there’s a path,’” he said.

Unfortunately, it turns out sleep apnea is one of several conditions that disqualifies patients like La Marca from the Bridge program. Here’s why, and what other options exist for GLP-1 drug coverage.

Restrictions on Medicare’s GLP-1 discount plan

It’s not that La Marca doesn’t qualify for Medicare coverage for weight-loss drugs. It’s that the Bridge discount plan is off limits to him because he has one of a number underlying conditions (including sleep apnea and Type 2 diabetes) that have been excluded from the pilot.

The program turns back such patients and directs them to Medicare Part D, a federally sponsored prescription drug plan run by private insurers. It covers weight loss drugs that are FDA-approved for conditions like sleep apnea.

But for someone like La Marca, that’s not a solution. Depending on the Medicare Part D insurer, he could end up shelling out a co-payment of anywhere from $200 to $600, according to KFF News, a division of the nonprofit health policy organization KFF.

That’s a lot more than $50 a month under the Bridge program. Not only is it a lot more money, but research suggests that getting coverage under Part D requires prior authorization from insurers. And that means jumping through hoops.

As reported in the NPR article, KFF’s Juliette Cubanski says it’s all about the money. She’s vice president and director of KFF’s Program on Medicare Policy.

The Bridge plan is a trial to see if subsidizing weight-loss drugs would actually save Medicare money long term — but as an 18-month pilot, it has been designed for cost containment.

So far, 600,000 Americans have signed up for Bridge in the past two months alone, according to Reuters. Cubanski calculates that 3.8 million Americans qualify under its current restrictions. If 2.85 million of them were to sign up, the 18-month pilot would cost an estimated $10 billion.

If the program were expanded to include people like La Marca who qualify under Medicare Part D, the cost of the trial would explode by billions more.