Prescriber quick reference: the GLP-1 Bridge PA
Published by GLP-1 Coverage Guide · Updated · No clinician review is credited for this page.
Short answer: For clinicians: the Medicare GLP-1 Bridge (July 2026 – December 2027) covers Wegovy, Zepbound (KwikPen only), and Foundayo at a $50 patient copay, outside the Part D benefit, via prior authorization to a central processor administered by Humana. Eligibility is BMI-tiered with specific comorbidity requirements, and three diagnoses reroute patients to standard Part D instead.
Sources for the coverage rules are listed below. An update date marks a revision; it does not imply a sitewide medical review.
Starting criteria, indication and prescriber eligibility
Document BMI and qualifying clinical criteria at GLP-1 therapy initiation. Uncontrolled hypertension means systolic above 140 or diastolic above 90 despite concurrent treatment with two antihypertensives. The heart-failure criterion is HFpEF.
A prescription for major cardiovascular-event risk reduction in established cardiovascular disease goes to Part D, even if weight management is also intended. Cardiovascular history alone is not a blanket Bridge exclusion. CMS does not require Medicare enrollment of the prescriber, but the prescriber must not be on the Preclusion List.
PA criteria at a glance
Document one: BMI ≥35 alone; BMI ≥30 with stage ≥3a CKD, heart failure with preserved ejection fraction (HFpEF), or uncontrolled hypertension; or BMI ≥27 with prediabetes, prior MI, prior stroke, or symptomatic PAD. Confirm enrollment in an eligible Part D plan type; excluded plan types require a separate standalone PDP. Exclusions that route to standard Part D coverage under existing indications: type 2 diabetes, moderate-to-severe OSA, and noncirrhotic MASH with moderate-to-advanced liver scarring (F2–F3 fibrosis) — for those patients, submit through the patient's drug plan under the applicable indication instead.
Prescribing specifics worth flagging: Zepbound must be prescribed as KwikPen for program processing (vials and single-dose pens reject); the $50 copay sits outside Part D, so it neither accrues TrOOP nor accepts LIS; and the demonstration currently ends December 31, 2027 — worth factoring into duration-of-therapy conversations.
Pharmacy claim before PA
Transmit the covered prescription to the pharmacy. The pharmacy submits a claim to Bridge BIN 028918, PCN MEDDGLP1BR, before you submit PA. An initial rejection requesting PA is expected. A regular Part D denial is not needed first.
The pharmacy typically transmits the PA request within 24–72 hours. If it has not arrived after 72 hours, CMS permits downloading and submitting the fax form after the pharmacy claim. CMS reports decisions within 72 hours of PA submission. There is no Bridge appeal; corrected, updated or additional information may be resubmitted.
Take the Medicare eligibility check →
Common questions
Where does the PA go?
To the program's central processor, administered by Humana — not to the patient's Part D plan. CMS's provider-facing program pages carry current submission specifics.
Does mild OSA exclude a patient?
No — only moderate-to-severe OSA triggers the Part D routing. Mild OSA patients remain Bridge-eligible under the normal tiers.
A patient qualifies under multiple tiers. Which do I document?
Any single satisfied criterion suffices; documenting the most robust one (e.g., BMI ≥35 alone) minimizes resubmission risk.
Related
Sources: CMS provider criteria and coverage routes · CMS PA form · Wegovy prescribing information: injection and tablet indications · CMS prescriber fact sheet