MA Plans Say No to Coverage of GLP-1s, CMS Pivots and Member and Medicare to Pay

As insurance companies raise flags about the cost of GLP-1 weight loss drugs in coordination with government payer programs, the Trump administration has rescinded its plan to have insurance companies fund coverage of the obesity drugs and will have Medicare pay the cost instead.

Last year, the White House announced a landmark deal with GLP-1 manufacturers Eli Lilly (Lilly) and Novo Nordisk (Novo) to lower prices for drugs in exchange for expanding access to the drugs through public payer programs like Medicare and Medicaid. STAT explains that for the deal to work out, insurers would have to agree to participate in a pilot payment model called Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) offered by the Centers for Medicare and Medicaid Services (CMS).

Just over 80% of Medicare beneficiaries are enrolled in a Medicare Part D plan for prescription drug coverage. Thus, Medicare Part D drug plans would need to participate in the BALANCE model for the deal with Lilly and Novo to have any viability.

On Tuesday, UnitedHealth, parent company to the largest Medicare Advantage insurer, UnitedHealthcare, raised concerns about the program during its first quarter conference call with investors, Reuters reports. Monday, April 20 had been the administration’s initial deadline for insurers to opt-in. Bobby Hunter, UnitedHealth chief of government programs, said  “challenges” and “outstanding questions” remain on the call. CVS Health, parent company of Medicare insurer Aetna, outright declined to participate.

According to Modern Healthcare, the Trump administration has opted instead to pivot and extend a temporary program through 2027 that will allow Medicare beneficiaries to purchase GLP-1 drugs while CMS uses the longer deadline to “collect data” about how patients will use them.