Medicare Bridge Program Prior Auth: Still work in progress at CMS?

[PatchyFog]

So the Medicare Bridge Program starts on July 1st to provide seniors access to GLPs outside of Part D for $50/month and will run for 18 months.

CMS (Medicare's parent) now has a dedicated Bridge Program web page:

Medicare GLP-1 Bridge | CMS

Centers for Medicare & Medicaid Services (CMS) announced the Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) Model and a separate short-term demonstration (now called the “Medicare GLP-1 Bridge”)

www.cms.gov

...but it appears the actual portal/process for a Primary Care Provider to submit a prescription and prior auth to the Bridge Program is still an unavailable work-in-progress at this time.

Does anyone know anything different?

 

[spanky2026]

That's what I've been hearing/reading too, over on a FB group of elderly glp users. Also that some docs are saying they aren't going to even submit, "don't have the staff to handle this," so patients having to find a provider who will. So, pretty much the cluster one would expect.

 

[PatchyFog]

"don't have the staff to handle this," so patients having to find a provider who will. So, pretty much the cluster one would expect.

Yeah. I'm one of those dicks with a concierge Doc, so he'll do what I ask, but doesn't look like the portal/intake process is setup yet. The website says the program is going to be run by Humanna (so I'll bet that goes well!)

 

[sheilarae74]

The website says the program is going to be run by Humanna (so I'll bet that goes well!)

That program is going to be a disaster then.

 

[grandpa_is_healthier]

I almost feel bad for my PHP for what she's going to need to do to with this program

 

[Ted R]

I have about minus 50 percent confidence that the government won't have this whole program totally fuxed up in short order. It's what they do best!

 

[PatchyFog]

Looks like provider guidelines are up now: https://www.cms.gov/files/document/glp-1-prescribers-c-1.pdf

As well as the PA form: https://www.cms.gov/glp-1-bridge.pdf

I don't like the "patients with apena have to go through regular part D" part of this. I tried to play that card a year ago with my UHC Advantage and was denied and denied again on appeal.

 

[PatchyFog]

Well, got my Doc to write on the Bridge day before yesterday. We discussed how to play the sleep apena thing, and he said, wink, wink: "Well, you've lost so much weight you probably don't have sleep apena anymore, so I'm comfortable putting it through to bridge." (Which is nonsense, I've done recent checks with a bluetooth pulse oximeter and I still dip.)

So now we'll see if Humanna cross-checks my records and bounces me on the pre-auth. Should know in a day or two (also curious how long this process will take).

 

[Good-Heart6425]

Yesterday my obese good friend was given a script for Wegovy despite his adverse reactions last year.he’s already taken Kaiser’s weight loss class. His Kaiser doctor seems to be resistant to writing a prescription for Zepbound Kwikpen that would trigger need for prior authorization to fill outside Kaiser pharmacies. I suggested he consider a telehealth provider consult to get a prior authorization prescription. https://www.cms.gov/files/document/glp-1-bridge.pdf

 

[PatchyFog]

In case this is useful for someone, here are my results of my 1st week of trying to get "on the bridge":

- PCP sends prescription to CVS. Notates "for CMS bridge", CVS sends it to my insurance anyway, where it is denied.

- PCP re-sends prescription to CVS with same notation. I call them immediately and tell them to send it to the Bridge. They ask me to come in to see my Medicare card and UHC Advantage. I do. We go over the prescription. Turns out, it is NOT ENOUGH for the PCP to just say "for the bridge" program, they must also provide the plan's BIN and PCN numbers.

So CVS corrected this and shot the script properly to Humana now, and my PCP should be getting a Bridge PA request shortly (perhaps on their CoverMyMeds electronic prior-auth (ePA) system).

 

[PatchyFog]

SUCCESS! ePA came in on my Doc's CoverMyMeds ePA platform bright and early Monday morning, he filled it out, and approval was granted about 4 hours later. Wow. SO I AM ON THE BRIDGE. (Had him write me for 15mg too, so I can stockpile.) Good-bye RUO chemicals bought from strangers on the Internet (at least until 2028 anyway).

So, at this time, they DO NOT appear to be cross-checking your records for things like Sleep Apnea, they just focus on the info in the prescription itself. So if you can get your Doc to look past that sort of thing, should need be, you're good to go. So, get on it, old people!

(Pharmacist said on Saturday she was seeing 80-90% acceptance rates into the bridge, which is encouraging...)

 

[PatchyFog]

BRIDGE program excludes sicker people;; those with milder comorbidities more easily qualify. https://www.medpagetoday.com/opinion/second-opinions/122244

Thanks for this. GREATEST HEALTHCARE SYSTEM IN THE WORLD, eh?