Reminder: Medicare Bridge prior authorization requests aren’t processed through Priority Health

We’re seeing an increase in Medicare prior authorization (PA) requests for GLP-1s for weight loss being submitted directly to Priority Health. As a reminder, GLP-1s for the treatment of weight loss are covered through the Medicare GLP-1 Bridge program, and PA requests should be submitted through the Medicare GLP-1 Bridge Program’s process, not through Priority Health. 

How the Medicare Bridge Program’s process works 

• Eligibility check: 
  • The prescribing provider sends a prescription for a GLP-1 medication to the patient’s dispensing pharmacy and includes the following information:
    • An obesity diagnosis code (the E66 family) 
    • A note to “Send to Bridge for weight management”
  • The pharmacy will submit a claim to the Medicare Bridge program, who will verify the patient’s eligibility.
  • If the patient meets eligibility criteria, the claim will be denied by Bridge and the pharmacy will be instructed to send a PA request form to the prescribing provider.
• PA request: The prescribing provider will receive the PA request form from the pharmacy either electronically or by fax. The provider must complete the form and submit it to the Bridge program.
• PA determination: A PA determination will be communicated to the prescribing provider via the Electronic Prior Authorization (ePA) portal or by fax within 72 hours of submission. The patient will also receive notification by mail.

Want more information? 

Visit CMS.gov or refer to CMS’s Medicare GLP-1 Bridge information sheet.