u/choaticbroccoli

As someone that works in a doctors office and submits PAs, I want to clear up some confusion about the GLP-1 bridge program.

I want to start by saying I appreciate that this program will get these meds to many people that need it, but it leaves a lot of Medicare beneficiaries behind.

If you have type 2 diabetes, moderate to severe obstructive sleep apnea, or MASH you do NOT qualify to use the program. You have to get a GLP-1 medication approved for those conditions through your Part D plan. Even if the Part D copay is astronomical, you still can’t use the bridge program if you have any of those 3 diagnoses.

It doesn’t matter if the provider doesn’t even use those diagnoses and only submits the PA for obesity, you still don’t qualify. When we submit the PA, the provider has to attest that you do NOT have those conditions. If the provider selects that you DO have any of them, the system automatically denies it and kicks it back saying it has to go through Part D. You can't get around this if you have these conditions because that would be committing Medicare fraud.

I submitted multiple of these PAs today and confirmed this is exactly how it’s being processed.

You do still qualify if you have mild obstructive sleep apnea and meet the other criteria, because mild OSA isn’t covered under Part D, only moderate to severe.

This is directly from the CMS website info for prescribers and the PA form that I've linked below. I recommend looking over these because this is exactly the guideline providers are following when submitting these PAs.

https://www.cms.gov/glp-1-bridge.pdf

https://www.cms.gov/files/document/glp-1-prescribers-c-1.pdf

I hope this information is helpful.

As someone that works in a doctors office and submits PAs, I want to clear up some confusion about the GLP-1 bridge program.

I want to start by saying I appreciate that this program will get these meds to many people that need it, but it leaves a lot of Medicare beneficiaries behind.

If you have type 2 diabetes, moderate to severe obstructive sleep apnea, or MASH you do NOT qualify to use the program. You have to get a GLP-1 medication approved for those conditions through your Part D plan. Even if the Part D copay is astronomical, you still can’t use the bridge program if you have any of those 3 diagnoses.

It doesn’t matter if the provider doesn’t even use those diagnoses and only submits the PA for obesity, you still don’t qualify. When we submit the PA, the provider has to attest that you do NOT have those conditions. If the provider selects that you DO have any of them, the system automatically denies it and kicks it back saying it has to go through Part D. You can't get around this if you have these conditions because that would be committing Medicare fraud.

I submitted multiple of these PAs today and confirmed this is exactly how it’s being processed.

You do still qualify if you have mild obstructive sleep apnea and meet the other criteria, because mild OSA isn’t covered under Part D, only moderate to severe.

This is directly from the CMS website info for prescribers and the PA form that I've linked below. I recommend looking over these because this is exactly the guideline providers are following when submitting these PAs.

https://www.cms.gov/glp-1-bridge.pdf

https://www.cms.gov/files/document/glp-1-prescribers-c-1.pdf

I hope this information is helpful.

If anyone would like a gif of a specific part of Iron Lung, drop the timestamp and I'll make it.