$50 Medicare GLP-1 'bridge' presents a difficult entry process
The GLP-1 "bridge" is confusing to get into and its benefits are questionable given its temporary nature.
With great fanfare, it was announced this week that Medicare beneficiaries with obesity would be able to get GLP-1 weight-loss drugs for a $50 monthly copay. Medicare previously covered the drugs "only when they were prescribed for specific health issues, such as sleep apnea or cardiovascular conditions."
The pilot program, called a "bridge," broadens coverage to "medications like Wegovy, Zepbound and Foundayo for individuals with obesity who are part of select Medicare plans," according to The New York Times. Coverage is set to run through the end of next year, with clinical protocols anticipating that patients will be assessed for discontinuation at 18 months.
But as Americans young and old know, federal programs are seldom as simple as they sound and enrolling in them isn't always easy.
This was confirmed by Ed, a Maryland retiree, and his wife Laura. "After arranging, a week ago, with Laura’s doctor to be ready to pull the trigger today when the 'bridge' opened, I was thrilled to see that my neighborhood Walgreens had received a prescription for one of the GLP-1s. But hold the phone … they want to charge me a little under $600 for it!" Ed told us.
James R. Hood
"Not quite sure ..."
Ed called the pharmacy and reached "a very pleasant woman who wasn’t quite sure how to handle this." After checking with others and running Laura's Medicare Part D numbers, the Walgreens lady said she had discovered that the standard procedure was for the pharmacy to deny the prescription.
The next step, she learned is for the prescriber – the doctor or other clinician – to download a prior-authorization form from the Centers for Medicare Services (CMS) website, and electronically send that form back to CMS, using a fax phone number, or web address, neither of which were available on the first day Ed inquired.
"I think what happens next is supposed to be that someone at CMS approves the pre-authorization form and sends the OK to the pharmacy to fill the prescription," Ed said.
The whole affair ate up about half an hour on the phone with Walgreens, then 15 minutes on the phone with the doctor and then another 10 minutes or so with Walgreens. This raises the question of how many Medicare recipients have the time, energy, investigative zeal and patience to go through the whole routine.
There is an FAQ sheet on the CMS site that spells out the process in the rather turgid prose we have come to expect of federal forms. Following the ins and outs is not easy for anyone but those willing to wade through it may reap the benefits – keeping in mind that those may be elusive and even questionable.
Risk-benefit analysis
This all sounds pretty good, if you can get through the denial/approval process but specialists are urging caution.
Rozina McCoy, of the University of Maryland's School of Public Health, quoted by the Times, said "the risk-benefit analysis for these medications differs considerably for older adults compared to younger individuals, as the potential for adverse effects is elevated."
Doctors interviewed by the Times said older patients should pair the drug with strength training and adequate protein intake because "dehydration can negatively impact kidney function and elevate the risk of fainting and falling."
Also, when patients discontinue GLP-1 therapy, an endocrinologist at the University of California, Los Angeles told the Times, "they often regain weight, but typically do not recover the same muscle mass as before; some of the lost muscle is replaced with fat."
Meanwhile, Ed and Laura are waiting, and hoping the notice on the Walgreen’s app soon changes from “Delayed – Awaiting insurance approval” to “Prescription ready for pickup.”
Updates
The story ends well. We got these updates from Ed late Friday:
Walgreens says the prescription is ready for pick-up! $50. On our way now to get it. Trust, but verify.
And then ...
Neither Laura’s doctor nor the pharmacy told her that Zepbound’s self-injecting KwikPen pen does not include a needle. Either a separate prescription for the needle is required or, according to the pharmacy, an over-the-counter needle can be used. (If you go to the “how to use” section of the website it does tell you that, but you have to look for that info.
50 OTC needles picked up. Pharmacist insisted on showing Laura how to attach needle to the syringe.
