u/MountainBubba

Kaiser was two weeks late to authorize PCPs to write prescriptions for people who qualify for the Bridge program. The Center for Medicare and Medicaid Services in HHS (CMS) announced it on May 6 and encouraged health care providers to work with CMS to get ready to go on July 1, so there's really no excuse for the delay.

Once Kaiser released the info, PCPs started prescribing and the pharmacy started issuing Prior Authorization requests for people who qualify for the program. There are three ways to qualify:

1. BMI of at least 35 at the start of self-pay for weight loss;
2. BMI of at least 30 AND a diagnosis of one or more of the following: (A) heart failure with preserved ejection fraction, (B) uncontrolled hypertension (defined as systolic blood pressure above 140 mm Hg or diastolic blood pressure above 90 mm Hg, despite concurrent treatment with two antihypertensive medications), or (C) chronic kidney disease stage 3a or above;
3. BMI of at least 27 AND a diagnosis of one or more of the following: (A) pre-diabetes (B) previous myocardial infarction, (C) previous stroke, or (D) symptomatic peripheral artery disease

You're disqualified if Part D is already paying for you to get a GLP-1 for sleep apnea or anything else.

My PCP qualified me over the phone and immediately shot a scrip to the pharmacy. I then called the pharm and told them I want to be in the Bridge program, which tells them what to do when the scrip is rejected by CMS. The next business day the pharm faxed the special Bridge PA request to CMS, and two days later I picked up my Zepbound.

They wanted to push me to Ozempic, but I tried it back in the day and didn't care for it. Kaiser's preference for Ozempic is weird because it's an inferior drug, and they won't say why they prefer it. As CMS doesn't care whether you take Ozempic, Zep, or Foundayo, Kaiser's "preference" is probably illegal. IMO, the hoops we have to jump through at Kaiser to get the better meds are, at least in part, markup-driven.

The process is kind of weird in that the initial scrip will be rejected by CMS. The PA request can't be filed until the scrip is rejected, which probably is a work-around to some IT issue. But that's OK because CMS turns the PA requests around almost immediately. Part D is set up to reject GLP-1s for weight loss although they will pay for them for people with OSA or Type II or a few other conditions.

People with these conditions can't switch to the Bridge program, but they can get doses high enough to work for weight loss anyhow. Congress doesn't want Medicare to pay for weight loss, so we need to fix that as the Bridge program is only happening for 18 months. Bridge is what’s called a demonstration program that should provide Congress with data justifying repeal of the “no weight loss meds for seniors” clause.

CMS is convoluted and weird, and so is Kaiser. Their interface does work pretty well despite all of that.

Here's a link to the Bridge program's info for prescribers, it has most of the deets.

CMS also has an online tool that determines eligibility (scroll down to "Can I participate in the GLP-1 Bridge program?)

Kaiser was two weeks late to authorize PCPs to write prescriptions for people who qualify for the Bridge program. The Center for Medicare and Medicaid Services in HHS (CMS) announced it on May 6 and encouraged health care providers to work with CMS to get ready to go on July 1, so there's really no excuse for the delay.

Once Kaiser released the info, PCPs started prescribing and the pharmacy started issuing Prior Authorization requests for people who qualify for the program. There are three ways to qualify:

1. BMI of at least 35 at the start of self-pay for weight loss;
2. BMI of at least 30 AND a diagnosis of one or more of the following: (A) heart failure with preserved ejection fraction, (B) uncontrolled hypertension (defined as systolic blood pressure above 140 mm Hg or diastolic blood pressure above 90 mm Hg, despite concurrent treatment with two antihypertensive medications), or (C) chronic kidney disease stage 3a or above;
3. BMI of at least 27 AND a diagnosis of one or more of the following: (A) pre-diabetes (B) previous myocardial infarction, (C) previous stroke, or (D) symptomatic peripheral artery disease

You're disqualified if Part D is already paying for you to get a GLP-1 for sleep apnea or anything else.

My PCP qualified me over the phone and immediately shot a scrip to the pharmacy. I then called the pharm and told them I want to be in the Bridge program, which tells them what to do when the scrip is rejected by CMS. The next business day the pharm faxed the special Bridge PA request to CMS, and two days later I picked up my Zepbound.

They wanted to push me to Ozempic, but I tried it back in the day and didn't care for it. Kaiser's preference for Ozempic is weird because it's an inferior drug, and they won't say why they prefer it. As CMS doesn't care whether you take Ozempic, Zep, or Foundayo, Kaiser's "preference" is probably illegal. It's a fair bet that the preference is financial. The price Kaiser pays Novo and Lilly is trade secret, but it's widely known that Ozempic has a much lower wholesale price than Zep and that Ozy is approved for more conditions.

The process is kind of weird in that the initial scrip will be rejected by CMS. The PA request can't be filed until the scrip is rejected, which probably is a work-around to some IT issue. But that's OK because CMS turns the PA requests around almost immediately. Part D is set up to reject GLP-1s for weight loss although they will pay for them for people with OSA or Type II or a few other conditions.

People with these conditions can't switch to the Bridge program, but they can get doses high enough to work for weight loss anyhow. Congress doesn't want Medicare to pay for weight loss, so we need to fix that as the Bridge program is only happening for 18 months. Bridge is what’s called a demonstration program that should provide Congress with data justifying repeal of the “no weight loss meds for seniors” clause.

CMS is convoluted and weird, and so is Kaiser. Their interface does work pretty well despite all of that.

Here's a link to the Bridge program's info for prescribers, it has most of the deets.

CMS also has an online tool that determines eligibility (scroll down to "Can I participate in the GLP-1 Bridge program?)

[Note: This was originally a reply, but I'm turning it into a post for visibility]