How Do I Get GLP-1 Coverage Through Medicare?

Once you have confirmed you are eligible, here is the process from start to first fill.

Step 1: Talk to your doctor

Ask whether a GLP-1 drug is appropriate for you and whether you meet the program's BMI and condition requirements. Your provider must certify that the drug is being used to reduce excess body weight and maintain weight reduction, combined with lifestyle modification including structured nutrition and physical activity. If physical activity is not clinically appropriate for you, that exception is allowed.

Step 2: Your provider sends the prescription to your pharmacy

It must be for a covered drug and covered form: Foundayo tablet, Wegovy injection or tablet, or Zepbound KwikPen. A Zepbound vial or single-dose pen will not process.

Step 3: The pharmacy verifies your eligibility

Your pharmacy may contact you for your Medicare Number, which is printed on your Medicare card. If you do not have your card handy, the pharmacist can look you up using the last four digits of your Social Security Number.

This step is not optional, and it has to happen first. Medicare requires the pharmacy to submit a claim to the GLP-1 Bridge and receive a denial before your prescriber can submit the prior authorization. If your doctor's office sends the PA first, it will not be accepted. If the office says they submitted it and nothing is happening, this is the usual reason.

A note on fraud: your pharmacy asking for this is normal. An unsolicited caller, text, or social media ad asking for it is not. If you suspect fraud, call 1-800-MEDICARE (1-800-633-4227).

Step 4: Your provider submits the prior authorization

Once the pharmacy claim has been submitted and denied, your doctor submits the Medicare GLP-1 Bridge prior authorization form. This goes to Medicare's central processor, not to your Part D plan.

Your prescriber can submit it two ways:

Electronically through CoverMyMeds
By fax to 1-800-530-2404

Only a prescribing clinician can submit this form. You cannot submit it yourself, so if you have the form in hand, pass it to your doctor's office. Your prescriber will need your Medicare Beneficiary Identifier (MBI) along with their own NPI and Tax ID, and they must complete every section.

If your doctor's office has not seen the form before, you can point them to the Medicare GLP-1 Bridge prior authorization request form on CMS.gov.

Step 5: You get a letter from Medicare

Medicare mails you a letter confirming your GLP-1 drug is covered under Medicare GLP-1 Bridge.

Step 6: Pick up your prescription and pay $50

You pay $50 for a one-month supply at the pharmacy counter.

Refills and dose changes

Your prior authorization is valid through December 31, 2027, and it covers refills and dose changes. You do not need a new approval each time. The one exception: if you switch to a different GLP-1 drug, your provider has to get a new approval.

If something gets stuck

Call 1-800-MEDICARE (1-800-633-4227) to ask about your eligibility or to check the status of your prior authorization. TTY users can call 1-877-486-2048. You can also call or text us at (312) 726-6565 and we will help you sort out where it is hung up.

Questions?

Call or text our Medicare team at (312) 726-6565, or call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

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Sources

This article is general information, not medical or coverage advice. Talk with your doctor about whether a GLP-1 drug is right for you, and confirm your own eligibility with Medicare.

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