AILSA CHANG, HOST:
If you're on Medicare, it can be tricky getting coverage for the blockbuster weight loss drugs known as GLP-1s. It depends on your exact diagnosis, and you might need to pay hundreds of dollars in copays or coinsurance. Last month, Medicare launched a pilot program that could streamline that process. Some eligible seniors will pay just $50 a month for the drugs. But as Jackie Fortier with our partner KFF Health News reports, many people with the most serious illnesses still will not get that discount.
JACKIE FORTIER, BYLINE: When Jeff La Marca heard about Medicare's new GLP-1 Bridge program, he thought he'd finally found a way to afford Zepbound. The retired professor has spent years trying to lose weight.
JEFF LA MARCA: And I said, thank God there's a path for it.
FORTIER: Medicare's temporary discount program applies to people who use the GLP-1 drugs for weight loss and only for weight loss. Patients who qualify pay just $50 a month. On the first day applications opened, La Marca's doctor in New Jersey submitted the paperwork. He was denied. To him, it didn't make any sense.
LA MARCA: I'm obese, You know, morbidly obese, BMI 42. I'm at risk for stroke. I'm prediabetic. And yet I can't get it.
FORTIER: La Marca is among an estimated 5.9 million Medicare enrollees who were locked out of the discount program because they have medical conditions like Type 2 diabetes or sleep apnea, conditions that GLP-1s treat. The Centers for Medicare & Medicaid Services runs the GLP-1 Bridge Program. It's a pilot that'll run for 18 months. Spokesperson Timothy Foster says the goal is to study whether Medicare can save money by treating obese patients upfront with GLP-1s before they develop more costly chronic health conditions. But there are eligibility rules around who can be part of the pilot. People like La Marca technically do have another option - go through their Medicare Part D prescription drug plans. In practice, though...
TAYLOR LACY: Coverage doesn't always mean paid for or affordable.
FORTIER: Taylor Lacy is a primary care physician in Kansas. She says patients often spend months jumping through insurance hoops to unlock Part D coverage, succeed and then get sticker shock.
LACY: In general, I would say my patients' copays are anywhere from 200 to $600.
FORTIER: Which is unaffordable. Lacy worries their health will get worse if they give up on getting the medicine.
LACY: They need treatment, and those are the people that are being neglected.
FORTIER: Without the medication, Jeff La Marca worries about his heart and about having a stroke.
LA MARCA: I'm terrified. I can't lose weight, and my sleep is horrible. My stress is beyond tolerable.
FORTIER: He eventually got his Medicare drug plan to cover Zepbound. But at the pharmacy, he found out his monthly copay would be hundreds of dollars. More than he could pay.
LA MARCA: I've got too much to do in my life yet, and I'd like to be healthy. I'd like to be a lot thinner. I'm tired of being fat.
FORTIER: The GLP-1 prescription he fought so hard to get approved is still too expensive for him to fill. It's still waiting at the pharmacy.
CHANG: Jackie Fortier is a reporter with our partner KFF Health News. Transcript provided by NPR, Copyright NPR.
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