On December 31, MedPage Today released an article titled, “New CMS Demo Aims to Increase Access to GLP-1s Under Medicaid and Part D” that describes the Better Approaches to Lifestyle and Nutrition for Comprehensive Health (BALANCE) demonstration program, designed to increase access to GLP-1 drugs for purposes of “weight management and metabolic health improvement” for Medicare Part D and Medicaid enrollees. The article quoted Marsha Simon’s comments on her interest in the expanded coverage indication for GLP-1s.
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.”