Medicare Part D’s GLP-1 Dilemma: Adam Colborn, JD

Medicare Part D plans are facing the same financial and utilization pressures facing other health care payers, but glucagon-like peptide-1 (GLP-1) therapies present a particularly difficult test of benefit design and budget sustainability, according to Adam Colborn, JD, vice president of government affairs at the Academy of Managed Care Pharmacy. The distinguishing feature for Part D is not how these drugs are used for diabetes, but how coverage for weight loss is being handled outside the traditional Part D benefit, according to Colborn.

Currently, Part D plans cover GLP-1 therapies when prescribed for diabetes and certain cardiovascular conditions, explained Colborn. However, for beneficiaries seeking GLP-1s specifically for weight loss, coverage is being routed through the federal Bridge demonstration program rather than through Part D. This structure means that Part D plans are not directly bearing the financial liability for the weight loss indication at this time.

Additionally, GLP-1s illustrate a broader structural challenge in the US health care system. They are relatively high-cost drugs with a very large potential patient population.

Colborn noted CMS estimates that approximately 13 million individuals could be eligible for GLP-1 therapy for weight loss under the Bridge program. That figure does not include Part D enrollees who qualify for GLP-1s based on diabetes or cardiovascular indications, further enlarging the potential treatment pool.

For now, Part D plans can lean on the Bridge program to absorb much of the financial risk associated with weight loss coverage while they focus on managing utilization and costs for diabetes and cardiovascular uses. Still, the scale and cost profile of GLP-1s signal that long-term strategies will be needed to balance clinical benefits with fiscal sustainability.

"The pressures facing Part D plans are the same as the pressures facing other types of payers," said Colborn in an interview with The American Journal of Managed Care^® (AJMC^®). “What's different about Part D is that plans cover GLP-1s for certain indications, including diabetes, while access to GLP-1s for weight loss for eligible Part D beneficiaries is currently being provided through a temporary CMS demonstration program known as the Bridge.”

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