The prior authorization form will ask physicians to attest that their patient does not have Type 2 diabetes, moderate to severe obstructive sleep apnea or MASH fatty liver disease.
Claims will not be processed before July 1.
“The Medicare GLP-1 Bridge seeks to test whether providing access to GLP-1 products at a uniform CMS negotiated net price will help improve beneficiary outcomes and reduce long-term Medicare spending,” Kelly Strachan, CMS health insurance specialist and Innovation Center fellow, said in the webinar.
The monthly $50 copay will not count toward a patient’s deductible or maximum out-of-pocket costs.
When asked what the plans are for the Bridge program at the end of 2027, Chaudhury said, “We understand that there’s a lot of interest from patients in understanding what’s going to happen after December 31st of 2027. We are looking forward to sharing more information as soon as we can on Medicaid.”
Who is eligible
To be eligible, beneficiaries must enroll in either a standalone prescription drug plan or Medicare Advantage coordinated care plan. CMS lists those enrolled in Special Needs Plans, employer/union group waiver plans and the Limited Income Newly Eligible Transition program as also being eligible to participate.
Beneficiaries of Tricare For Life, the Medicare-wraparound coverage for military retirees and dependents, can also access the Bridge program, but they must also be enrolled in an eligible Part D plan type. Dual enrollees in both Medicare and Medicaid can also be eligible.
Catherine Varney, an obesity medicine physician and trustee at the Obesity Medicine Association, was asked during OCAN’s webinar to describe the ideal patient to benefit from GLP-1 Bridge.
“Those at greatest risk of obesity and obesity-related diseases,” said Varney. “We know that obesity is not a benign disease … it’s associated to over 200 chronic conditions and 13 different types of cancers.”
Qualifications will vary based on the patient’s body mass index (BMI), and there is a minimum BMI to be eligible.
Beneficiaries must be at least 18 years old and have a BMI of 27 or higher and must also be diagnosed with at least one of the following conditions: prediabetes, a previous myocardial infarction, a previous stroke or a symptomatic peripheral artery disease.
Those with a BMI equal to or greater than 30 must also be diagnosed with heart failure with preserved ejection fraction, uncontrolled hypertension or chronic kidney disease stage 3a or above.
Patients with a BMI of 35 or greater do not require an additional diagnosis to participate in the Bridge program.
Regulatory concerns
Strictly speaking, the Bridge program is operating outside the normal scope of Medicare, which is prohibited from covering medications solely indicated for weight loss. By opening up Medicare to obesity medicine prescribers, some worry that the program could introduce potential avenues for fraud or misuse.
Christopher Frisina, healthcare regulatory counsel at the law firm Alston & Bird, noted that many people get telehealth visits that are considered sufficient to obtain a prescription eligible for the Bridge program.
“I think maybe that this GLP-1 Bridge program might inspire new telehealth providers or existing telehealth providers that to this point haven’t taken Medicare reimbursement to move into this space,” Frisina told The Hill. “And it’s a risky place, because Medicare requires more diligence in business practices than a lot of businesses do.”
Frisina acknowledged that CMS appears to have done its due diligence in setting up the demonstration program but cautioned that fraud is always a possibility.
“It requires the provider to fill up this really detailed prior authorization form to send that in before approval can happen. So, you have a check and balance that requires the coordination between two different entities — the provider and the pharmacy — to actually get the fraud,” he said. “It’s not going to be as straightforward as some of the fraud schemes that we often see, but I don’t think it’s outside of the realm of possibility.”
When it comes to how much the demonstration will cost, CMS has not given a clear picture.
“CMS has not publicly released cost estimates or enrollment projections for the Medicare GLP-1 Bridge demonstration model,” an agency spokesperson told The Hill.
“Under the Medicare GLP-1 Bridge, eligible Medicare Part D beneficiaries will have a $50 copay per monthly supply of an eligible GLP-1 drug,” they added. “Because the demonstration operates outside of the Medicare Part D benefit’s coverage and payment flow, it does not follow the standard Part D structure for cost-sharing, deductibles, or out-of-pocket accumulation.”
