More GLP-1 options are coming for federal retirees, but they come with a catch

OPM requires FEHB plans to cover at least one GLP-1 prescribed for weight loss, and this extends to any Part D or Medicare Advantage plan offered by an FEHB carrier. As a result, most annuitants with federal retiree coverage have had a path to these drugs for years.

But that hasn’t been true for the broader Medicare population. When Congress created Part D more than two decades ago, it explicitly excluded coverage of drugs prescribed solely for weight loss or gain, meaning Medicare beneficiaries without employer-sponsored retiree benefits could only access GLP-1s if they had a qualifying condition like diabetes or cardiovascular disease.

This summer, that changes. CMS is launching the Medicare GLP-1 Bridge program, which will extend coverage of certain GLP-1 medications for weight loss to eligible Medicare beneficiaries, regardless of whether they have an underlying medical condition. 

For annuitants enrolled in Part D, this program could expand your options. Here's what it covers, who qualifies, and what it means for you.

What is the Medicare GLP-1 Bridge Program?

CMS is launching this demonstration project on July 1, and it will provide access to a limited selection of GLP-1 weight loss drugs to eligible Medicare Part D beneficiaries. The program will operate outside of Part D’s benefit and payment structure. CMS is establishing a central processor to run the program.

Who qualifies for the program?

Medicare beneficiaries enrolled in Part D either from a standalone prescription drug plan (PDP) or from a Medicare Advantage plan that bundles Part D (MA-PD) who meet the prior authorization criteria are eligible. FEHB carriers provide Part D options through employer group waiver plans (EGWPs), and these types of plans are eligible for the program.

For the beneficiary to qualify, a provider must submit a prior authorization request to the program that attests “the beneficiary is prescribed the requested drug to reduce excess body weight and maintain weight reduction in combination with current and ongoing lifestyle modification including structured nutrition and physical activity consistent with the applicable FDA approved label, and the beneficiary is at least 18 years of age with a BMI greater than or equal to 35.” For beneficiaries with underlying medical conditions, the BMI threshold is lowered to 30 or 25 based on the diagnosis.

Will I save money in this program?

Not necessarily. The GLP-1 Bridge Program charges a $50 copay for each covered drug, which could be more than what you’d pay with Part D coverage from your FEHB plan. For example, the .25mg injectable version of Wegovy is $35 from the Part D plan with BCBS Standard and $45 from the Part D plan with BCBS Basic. 

You’ll need to check the prescription drug pricing tool on your FEHB carrier’s website and compare prices to find out if there are any savings.

Will I have greater access to GLP-1’s in this program?

Probably, and this will likely be the biggest advantage for federal annuitants. The GLP-1 Bridge Program provides access to all formulations of Wegovy and Foundayo, and the KwikPen formulation of Zepbound.

While OPM requires each FEHB plan to cover GLP-1 medications, they aren’t required to cover all of them. For example, BCBS covers Wegovy in their Basic and Standard plans, but they don’t cover Zepbound and Foundayo. In fact, Foundayo just received FDA approval last month and many FEHB plans aren’t yet covering this medication. Annuitants should go to the carrier website for their plan and use the prescription drug lookup tool to see which medications the plan covers.

Are there reasons not to use this program?

Yes. Since this program operates outside of your Part D plan, it means that the $50 copay does not go toward the Part D catastrophic limit ($2,100 in most FEHB Part D plans) or the medical catastrophic limit of your FEHB plan. Not having those costs counted could lead to higher overall out-of-pocket costs.

This demonstration project also has an expiration date of December 31, 2027, at which point it could lead to greater GLP-1 adoption in the Medicare program, or it could simply be terminated. 

I’m subject to IRMAA and have opted out of Part D, should I reconsider?

Maybe. You'll need to weigh the Part D IRMAA surcharge against the potential drug cost savings. Here's an example using Wegovy (0.25mg injectable):

• Without Part D (BCBS Standard): $640.30/month
• With Part D (BCBS Standard): $35.00/month
• Highest IRMAA surcharge: $91.00/month

Even at the highest IRMAA tier, enrolling in Part D would cost you $126/month ($35 drug cost + $91 surcharge), a savings of $514.30/month compared to paying out of pocket with regular prescription drug coverage from BCBS Standard. It's also worth noting that Part D eligibility only requires Part A enrollment, so if you've opted out of Part B, you don't need to enroll to access Part D savings.

How do I use the GLP-1 Bridge Program?

Talk with your doctor, not your FEHB plan. They’ll submit the prior authorization request to the program’s central processor for an eligible GLP-1 drug. You’ll pick up your medication at the pharmacy and pay the $50 copay there. More operational details will be forthcoming from CMS in the next few weeks prior to the July 1st launch.

Kevin Moss is a senior editor with the Guide to Health Plans for Federal Employees provided by Consumers’ Checkbook. Watch more of his free advice and check here to see if the Guide is available for free from your agency. You can also purchase the Guide and save 20% with promo code GOVEXEC.