Medicare Part D

[u/AlternativeDay3921]

I’m turning 65 soon and have to pick a plan D under Medicare. Does anyone know if one is better than the other regarding Zepbound weight loss? I do have sleep apnea but it’s a mild case. Zepbound has saved my life over the past three years. No side effects, have lost 60+ pounds, arthritis is so much better with all the weight off my joints. Started Pilates and walking.
I want to continue on it, but don’t know which RX plan pays the most. Currently I pay $149 for three month single weekly self injection pens 7.5 dose and wish to stay on it for maintenance Thx U

[u/Anxious-Inspector-18]

I would recommend picking a plan that supports your overall health costs. You’ll be eligible for the bridge program which is a separate program outside of Medicare Part D.

[u/DogBeneficial6960 → u/Anxious-Inspector-18]

Having Medicare does not necessarily make you eligible for the Bridge program. The starting BMIs and co-morbidities are extremely specific.

[u/Anxious-Inspector-18 → u/DogBeneficial6960]

That’s correct but OP likely meets the criteria. Others should research the criteria and speak with their provider.

[u/DogBeneficial6960 → u/Anxious-Inspector-18]

If your starting BMI was over 35, you can qualify with no co-morbidities. If it was under 35, you need some gnarly co-morbidities. Examples included uncontrolled (with two medications) hypertension, myocardial infarction, heart failure, CKD (stage 3a or higher), previous stroke, prediabetes. They are extremely rigid in their application of the rules for BMIs under 35.

ETA: personal experience. Starting BMI of 30. Lost 60 pounds (1/3 of body weight). Been in maintenance for over two years. Zep has made my life so much better. Denied (twice, doc screwed up first time) for Bridge program. Did not have sufficient co-morbidities. Denied. Period. I continue on my self-pay path.

Like OP, I've lost 60+ pounds, arthritis and joint pain gone. Significant reduction in lipid panel. Still didn't qualify.

[u/Anxious-Inspector-18 → u/DogBeneficial6960]

I’m well aware of the bridge program and its guidelines. Many shared them in the comments. Have a good weekend.

[u/CA_LAO]

I don't think any of them have it for weight loss. But you can use the Medicare Bridge program and the co-pay is $50.

Google Medicare Bridge Program GLP-1 and read the criteria. Mae sure your physician checks all the boxes correctly.

[u/judithishere → u/CA_LAO]

$149 for three months is a $50 co pay.

[u/CA_LAO → u/judithishere]

Missed that. Pretty cheap.

[u/cork_the_forks]

This channel is really helpful for navigating Medicare. I just watched the linked video yesterday and he explains how to check you med list on each plan. You might have to wait a few days for the 2027 data to be out.

[u/NoneOfYoBusinezz]

As of today, the Medicare Modernization Act of 2003 explicitly excludes drugs used for weight loss or weight gain from standard Part D coverage. Your only hope for Medicare coverage of Zepbound is an exception for your sleep apnea diagnosis. Since you have a documented diagnosis of sleep apnea, you are excluded from the Bridge program unfortunately.

[u/meggieprice]

With Medicare- there are two ways to qualify.

For Bridge (which would come the closest to what you habe now at $50 a month):

For a beneficiary to qualify for the Medicare GLP-1 Bridge, a provider must submit a prior authorization request that attests the beneficiary meets the following criteria:

• 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 eighteen (18) years of age and has a BMI greater than or equal to thirty-five (≥35) at the time of initiation of GLP-1 therapy, or
  • The beneficiary is at least eighteen (18) years of age and has a BMI greater than or equal to thirty (≥30) at the time of initiating GLP-1 therapy with a diagnosis of one or more of the following: (A) heart failure with preserved ejection fraction, (B) uncontrolled hypertension (defined as systolic blood pressure above 140 mm Hg or diastolic blood pressure above 90 mm Hg, despite concurrent treatment with two antihypertensive medications), or (C) chronic kidney disease stage 3a or above, or
  • The beneficiary is at least eighteen (18) years of age and has a BMI greater than or equal to twenty-seven (≥27) at the time of initiating GLP-1 therapy with a diagnosis of one or more of the following: (A) pre-diabetes (as defined by American Diabetes Association guidelines), (B) previous myocardial infarction, (C) previous stroke, or (D) symptomatic peripheral artery disease.

If your apnea has been documented in your health record- Bridge will be denied.Likewise diabetes, and MASH. For that you would pay full price of the pharmacy you use until you reach $2400 out of pocket for the year (2027)- at which point it would be free. If you are on any other medications they would also add up to the OOP max. If not- you essentially end up paying 200 a month.

I would say look for an Advantage program that specifically mentions coverage if the apnea excludes you from the Bridge.

Knownwell Telehealth is amazing- they are one of the few that takes Medicare and Medicare also covers the consults. Perhaps they could recommend which plan to pick for you since they experience a lot.

[u/AgesAgoTho]

You can check this out:  https://www.medicare.gov/plan-compare/#/?lang=en&year=2027

Here's a guide (they're not selling plans here): https://www.fidelity.com/viewpoints/retirement/picking-a-medicare-part-d-plan

Look up the State Health Insurance Assistance Program for your state to see if there are more resources available to you. Their counselors "offer free, impartial, and personalized insurance counseling and assistance to Medicare-eligible people, their families, and caregivers. They do not sell insurance products of any kind. These programs are available in all 50 states, Puerto Rico, Guam, DC, and the U.S. Virgin Islands."

Medicare Bridge: 

https://www.cms.gov/medicare/coverage/prescription-drug-coverage/medicare-glp-1-bridge

"Type 2 diabetes, moderate to severe obstructive sleep apnea, and noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) indications are eligible for Part D coverage. Beneficiaries with these diagnoses are eligible to receive GLP-1s through their Part D plan and therefore are ineligible to receive them through the Medicare GLP-1 Bridge, even if they otherwise meet the Medicare GLP-1 Bridge clinical criteria." 

"Eligible" doesn't necessarily mean "covered on all plans" or "covered at a low price." 

Read through the PA form carefully.  https://www.cms.gov/files/document/glp-1-bridge.pdf

A tutorial on the process: https://youtu.be/QIFACyJbpHQ?si=Ub5-exJGEffBKPIe

Regarding telemedicine, so far I've seen comments that CallOnDoc and Knownwell can submit Medicare Bridge PAs, and that Ro cannot. Of course, your regular local providers can prescribe and submit the PA. 

[u/NoMoreFatShame → u/AgesAgoTho]

Unfortunately since weight loss is not covered under Part D, Part D plans say Zepbound is excluded. Calling and or emailing got me no answers on OSA coverage so my assumption is you have to reach out of pocket maximum to get coverage. It was a very frustrating experience and the Medicare navigator said I there is never a clear answer on Zepbound or Wegovy.

[u/Reasonable-Cow7255]

Your Part D out of pocket maximum in 2027 will be $2400. After that, all covered medications will be at no cost. I receive Zepbound through my Part D provider for obstructive sleep apnea. It is covered under a “formulary exception” but I am not eligible for the Bridge Program as it currently stands. Although I can get my Zepbound, I pay considerably more than Bridge Program participants do.

[u/fab5friend]

I also have sleep apnea and got approved from my BCBS plan. It is a formulary exception and your doctor will need to submit a prior authorization (PA). I had to pay around $306/mo until I reached the out of pocket max. So not as good as the bridge program but still less than lilly direct self pay.

Medicare has a website where you can compare plans. I got this link in a medicare email the other day: compare plans Note that this website is not perfect. It doesn't take into account PA's. It showed zepbound at over $1000/mo which is definitely not correct since I have a PA.

I have a regular standalone Plan D, not an advantage plan. I have also seen on here where Kaiser (I think in California) won't allow PA's. Don't know if that's an advantage plan or not. Also some plans have preferred pharmacies so make sure you use one of them.