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From an overall perspective, “it would be very helpful if the administration would address the Part D statutory prohibition on weight-loss drugs,” she wrote in an email. But “I understand the reluctance to take that step unless the basis for Medicare coverage is also addressed which, due to a court decision, prohibits CMS from considering the cost of a service or item, including drugs.”

“Thus, it is the responsibility of Congress to revisit the policy question of whether cost should be a consideration in Medicare coverage,” she said.

However, Simon added, “I would not hold my breath, as Congress has been unable to decide on much simpler issues such as the extension/reform of the [Affordable Care Act] exchange premium subsidies and cost-sharing reductions.”

Simon also was skeptical about the administration’s ability to significantly lower GLP-1 prices. “Even with the rivalry between Lilly and Novo Nordisk for this market, I am not sure that the administration can negotiate a better price than the Part D sponsors — especially as the administration is also negotiating a reduced price for their Trump Rx direct-to-patient drug sales [website] which is $350 per month with no insurance coverage,” she wrote. “Currently, Lilly offers [tirzepatide (Zepbound)] direct to consumers for about $250/month which seems to be the best price the manufacturers are interested in offering.”

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“This is not actually the first time that prior authorization has been used in traditional Medicare, according to Marsha Simon, PhD, adjunct professor of health policy at George Washington University in Washington. Prior authorization has worked well there when it comes to the purchase of electric scooters and the use of ambulances to transport patients to routine dialysis appointments; both of those items had been involved in allegations of fraud or overuse, she said.

“It’s not prior authorization that’s the problem; it’s the vendors who are conflicted,” said Simon. She was referring to the information technology (IT) vendors that CMS has contracted with to implement the WISeR Model. Under the model, the vendors are paid a share of the savings generated by the claims that they deny.”

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