Medicare GLP-1 Bridge Program FAQ's

The Medicare GLP-1 Bridge Program was designed to increase access to GLP-1 medications for beneficiaries who seek the drug solely to reduce excess body weight or maintain weight reduction. For complete information, visit https://www.cms.gov/.

What is the CMS Bridge Program?

The Centers for Medicare & Medicaid Services (CMS) Medicare GLP-1 Bridge is a federal program that provides eligible Medicare beneficiaries access to certain GLP-1 medications for $50 per month through December 31, 2027. It is a high-visibility, policy-sensitive initiative with bipartisan implications. CoverMyMeds provides operational workflow support to enable the GLP-1 Bridge program to function.

Notable Program Information

Prescriptions should be directed to the Part D plan for:

• Moderate to severe obstructive sleep apnea (OSA)
• Noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) with moderate to advanced liver scarring (fibrosis)
• Type 2 diabetes

If the patient may be eligible for coverage under the Medicare GLP-1 Bridge:

• No Part D plan rejection is required — transmit the prescription to the pharmacy using the standard process.
• It is recommended to include an obesity diagnosis code, such as the E66 family.
• Providers should wait for the pharmacy to initiate a Medicare GLP-1 Bridge prior authorization request before attempting to submit the prior authorization.

Frequently Asked Questions

1. I was directed to CoverMyMeds by CMS, Humana or the Medicare GLP-1 Bridge Program regarding the status, approval, denial or receipt of my request. Can CoverMyMeds assist with these questions?

CoverMyMeds supports electronic prior authorization workflow connectivity for the Medicare GLP-1 Bridge Program. CoverMyMeds does not review, approve or deny Medicare GLP-1 Bridge Program prior authorization requests.

If this request was submitted directly to the Medicare GLP-1 Bridge Program by fax or phone call, CoverMyMeds does not have visibility into receipt, status, approval or denial information for that submission.

For questions regarding request status, approval decisions, denial decisions or fax submission receipt, please contact the Medicare GLP-1Bridge Program directly.

2. How does a patient qualify for the CMS Bridge Program?

CoverMyMeds supports the access workflows behind the program. For specifics on who qualifies and how to enroll, visit the Medicare website and search for "Weight Loss Drugs."

3. Can a prescriber start a prior authorization request using the BIN, PCN and Rx Group?

The preferred workflow is for the pharmacy to initiate the prior authorization request. This enables the pharmacy to attempt to process the claim first. If a prior authorization request is required, the pharmacy will then initiate the prior authorization.

The correct workflow is to send the prescription to the pharmacy, allow them to submit the claim and then respond to the prior authorization request once it is initiated by the pharmacy.

4. What should the provider do if they do not hear back from the patient’s pharmacy?

If the provider has not heard back from the pharmacy, they should visit the CMS website to continue the process.

5. How can the CMS Bridge Program prior authorization form be found?

Please visit CMS.gov and search for “Medicare GLP-1 Bridge.”

The form can be found on the CMS program page. You may need to scroll toward the bottom of the page to locate the Medicare GLP-1 Bridge Prior Authorization Request Form.

6. How should eligibility errors such as “patient not found” be handled?

These appear to be standard eligibility mismatches where patient data submitted does not match the payer's records.

Users should review and correct patient information and resubmit.

If a user has found the form on the CoverMyMeds website and submitted the prior authorization request, it is likely they may experience an eligibility error if the pharmacy has not submitted the Bridge claim to the central processor.

Providers should first work with the pharmacy to verify the information submitted on the Bridge claim. If the mismatch remains unresolved, they can use the fax form process or contact Humana for additional support.

7. Can providers appeal a denial?

No. Appeals are not supported through the CMS Bridge program. Providers should resubmit the prior authorization request using the Renewal function and include any additional relevant information as appropriate.

8. What if the patient’s pharmacy does not use CoverMyMeds?

If a pharmacy claim has been denied, the provider may proceed through the CMS form process. Visit the CMS website to access and download the required fax form directly from CMS.