Heart failure with preserved ejection fraction (HFpEF) and the Medicare GLP-1 Bridge
Published by GLP-1 Coverage Guide · Updated · No clinician review is credited for this page.
Short answer: CMS lists heart failure with preserved ejection fraction (HFpEF) as a Tier 2 qualifying condition, with a BMI of 30 or higher at the start of GLP-1 therapy. A general heart-failure diagnosis is not enough to establish this condition requirement. You must also meet the other program criteria, and your prescriber submits the prior authorization.
Sources for the coverage rules are listed below. An update date marks a revision; it does not imply a sitewide medical review.
Which heart-failure diagnosis CMS names
The CMS provider guidance names heart failure with preserved ejection fraction. Question 10 of the Bridge prior authorization form asks specifically about this diagnosis. Heart failure with reduced ejection fraction (HFrEF) alone does not satisfy the listed HFpEF criterion. Ask your prescriber to confirm the documented diagnosis rather than inferring eligibility from symptoms, a medication, or a general description of heart failure.
This heart-failure criterion was checked against the CMS provider guidance and prior authorization form on October 5, 2026.
What your prescriber needs to confirm
For this Tier 2 path, your prescriber needs to document HFpEF and a BMI of at least 30 when GLP-1 therapy began. CMS says the BMI at therapy initiation applies even if you have since lost weight. Your prescriber must also confirm the remaining eligibility criteria and whether the requested medication is appropriate for you.
BMI at the start of GLP-1 therapy
Already taking a GLP-1? Use your height and weight when therapy first started. CMS accepts qualifying starting criteria from before Medicare enrollment or July 2026. If starting therapy now, use pre-treatment measurements. Ask your prescriber for records if you do not know.
Take the full 2-minute eligibility check →
Common questions
Does 'diastolic dysfunction' count as heart failure?
Do not assume it does. CMS names HFpEF specifically. Ask your prescriber whether your documented diagnosis meets that criterion; a general description of diastolic dysfunction does not establish eligibility on its own.
Does heart failure with reduced ejection fraction (HFrEF) qualify?
HFrEF alone does not meet the heart-failure condition CMS lists for Tier 2: that condition is HFpEF. You may still meet another eligibility path, such as BMI 35 or higher at therapy initiation or a different qualifying condition. Ask your prescriber to check the full criteria.
Are GLP-1s safe with heart failure?
Meeting a coverage criterion does not establish that a medication is suitable for you. Your prescriber should assess the specific drug, your diagnosis, other medications, and individual risks before prescribing.
Related
Criteria source: CMS — provider eligibility criteria · CMS — prior authorization form (Question 10)