Medicare GLP-1 Bridge | CMS
Summary: This document is the official Medicare GLP-1 Bridge Prior Authorization Request Form used by healthcare providers to request coverage for GLP-1 medications like Foundayo, Wegovy, and Zepbound when patients do not meet standard Part D criteria.
The Medicare GLP-1 Bridge Prior Authorization Request Form is a mandatory document for providers seeking coverage for specific GLP-1 medications (Foundayo, Wegovy, and Zepbound) for patients who do not have a Part D-eligible diagnosis (such as type 2 diabetes, OSA, or MASH). The form requires documentation of a denied pharmacy claim from the GLP-1 Bridge BIN (028918) and PCN (MEDDGLP1BR) prior to submission. It includes a comprehensive clinical questionnaire covering patient BMI, pre-diabetes status, and history of cardiovascular conditions to determine eligibility for weight management support.
Document outline
1. Instructions for Part D eligible diagnoses vs. GLP-1 Bridge eligibility 2. Required documentation: Denied pharmacy claim (BIN 028918, PCN MEDDGLP1BR) 3. Patient and Prescriber Information fields 4. Requested drug selection (Foundayo, Wegovy, Zepbound) 5. Clinical Questionnaire (Q1-Q12): 6. - Part D eligibility acknowledgment 7. - OSA and MASH diagnosis verification 8. - Type 2 diabetes status 9. - BMI classification for weight reduction therapy 10. - Pre-diabetes and cardiovascular history (MI, stroke, PAD, heart failure) 11. - Comorbidity assessment (hypertension, chronic kidney disease) 12. Prescriber signature and legal declaration