Information for Providers | CMS
Summary: This document is the official Medicare GLP-1 Bridge Prior Authorization Request Form, used by clinicians to request coverage for weight management medications when patients do not meet specific Part D criteria.
The Medicare GLP-1 Bridge Prior Authorization Request Form is designed for prescribing clinicians to request coverage for Foundayo®, Wegovy®, and Zepbound® for patients seeking weight reduction. The form outlines specific criteria for Part D eligibility, noting that patients with conditions such as type 2 diabetes, obstructive sleep apnea, MASH, or established cardiovascular disease should submit requests directly to their Part D plan. For patients without these diagnoses, this form facilitates the request through the GLP-1 Bridge program. It requires patient and prescriber information, clinical details including BMI and comorbidities, and a prior denied pharmacy claim from the GLP-1 Bridge BIN/PCN.
Document outline
1. Submission Instructions (Electronic/Fax) 2. Part D Eligibility Criteria and Routing 3. Patient and Prescriber Information Fields 4. Drug Selection (Foundayo, Wegovy, Zepbound) 5. Prerequisite: Denied Pharmacy Claim Requirement 6. Clinical Questionnaire (BMI, Comorbidities, Medical History) 7. Prescriber Attestation and Signature