If you're a Medicare patient hoping to access a GLP-1 obesity management medication through the Medicare GLP-1 Bridge program, you'll need a prior authorization (PA) before you can fill your prescription.  

The good news: you don't have to manage any of this paperwork yourself. But the process does work differently than most insurance prior authorizations, so it helps to know what to expect before you start.

First, who is eligible for GLP-1 coverage under Medicare Bridge?

To be eligible, you must be enrolled in Medicare Part D and meet at least one of the following body mass index (BMI) based criteria:

BMI of 35 or higher: qualifies on its own, with no additional diagnosis required.

BMI of 30 or higher with at least one of the following conditions:

• Heart failure with preserved ejection fraction (HFpEF),

• Uncontrolled hypertension, or

• Chronic kidney disease, stage 3a or above

BMI of 27 or higher with at least one of the following conditions:

• Pre-diabetes,

• Prior myocardial infarction (MI),

• Prior stroke, or

• Symptomatic peripheral artery disease.

Note that prior authorization will still be required for this group.

One important exception to be aware of: if your GLP-1 medication is already covered under your standard Part D plan for a different approved indication — such as Type 2 diabetes, moderate to severe sleep apnea, cardiovascular risk reduction, or MASH — the Bridge program will not apply to your prescription. Coverage for those indications continues through your standard Part D formulary.  

If you're unsure which category applies to you, your knownwell clinician can help assess your eligibility at your visit. Book a visit with a knownwell clinician.

What is prior authorization, and why is it required?

Prior authorization is a step that requires your clinician to confirm you meet specific eligibility criteria before your medication is covered. For the Medicare GLP-1 Bridge — the temporary program running July 1, 2026, through December 31, 2027, that covers Wegovy®, Zepbound®, and Foundayo® for weight management — prior authorizations exist to verify that you qualify based on your BMI and any related health conditions.

What are the steps for getting a prior authorization under the Medicare Bridge program?

Most people assume the prior authorization happens before the prescription is sent anywhere. With the Medicare GLP-1 Bridge, it actually works in reverse. It's worth understanding why, so the process doesn't feel confusing if you're waiting on your medication.

Step 1: If you meet the program eligibility and clinical criteria, your clinician writes your prescription and sends it to the pharmacy.
Your clinician writes a prescription for one of the covered GLP-1 medications and sends it to a participating pharmacy. The pharmacy submits the claim using the Bridge program's specific billing information (called the Bridge BIN/PCN), along with your Medicare Beneficiary Identifier (MBI).

Step 2: The pharmacy claim is rejected. This is expected.
If it's your first fill, the claim will initially be rejected before a prior authorization form is sent to the prescribing clinician. This rejection isn't a denial, it's the system's way of flagging that a prior authorization is needed before coverage can be confirmed. The pharmacy will receive messaging explaining the next step. You do not need to do anything else.  

Step 3: The PA request is routed back to your clinician.
The pharmacy will send the prior authorization request form to your clinician, typically within 24–72 hours. This form is sent via electronic PA (ePA) or fax. Your patient record is created in the central processor's system at this point.

Step 4: Oue care team completes and submits the PA.
Your clinician fills out the PA form, attesting that you meet the Bridge program's clinical eligibility criteria — including your BMI at the time you started GLP-1 therapy and that the medication is being prescribed for weight management, not for Type 2 diabetes, obstructive sleep apnea, or MASH, which are covered separately through standard Part D.

Step 5: The PA is reviewed and decisioned.
Humana serves as the central processor for the Bridge program and is responsible for managing prior authorization, claims adjudication, and payment to pharmacies. There will likely be delays as Humana processes a high volume of prior authorization submissions.

If the PA is approved, the pharmacy re-runs your claim, it processes, and you pick up your medication — paying a $50 copay for a 30-day supply. Both you and your clinician receive a letter confirming approval.  

If the PA is denied because you don't meet the Bridge eligibility criteria, you and your clinician will also receive a letter explaining why.

Step 6: knownwell notifies you of the outcome.

knownwell's care team will notify you once Humana has made a determination. If your prior authorization is approved, we'll confirm next steps and let you know your medication is ready to be picked up at your pharmacy.  

If your prior authorization is denied, we'll reach out to explain what that means for you and discuss alternative options — including whether an appeal may be appropriate or whether there are other pathways we can explore together.  

What happens if my prior authorization is denied?

If your prior authorization is denied, knownwell's care team will review the reason for the denial and take next steps on your behalf.

If the denial appears to be an error or improper rejection, our care team will contact Humana directly to confirm and resubmit the prior authorization.

If the denial is confirmed because you don't meet the Bridge program's clinical criteria or eligibility requirements, our care team will reach out to let you know. From there, you're welcome to connect with your clinician to talk through what this means for you and explore any alternative options that may be available.

What does the clinician attest to in the prior authorization?

Your clinician confirms that your GLP-1 is being prescribed for weight management and that you meet the program's BMI thresholds — either a BMI of 35 or higher, or a BMI of 30 or higher with at least one qualifying condition such as heart failure, uncontrolled hypertension, or chronic kidney disease stage 3a or above.

Importantly, eligibility is assessed based on when you first started GLP-1 therapy, not necessarily when the PA request is submitted. So if you started a GLP-1 before enrolling in Medicare or before the Bridge launched, your clinician can attest to your BMI and conditions at that earlier point in time.  

Do you need a new prior authorization for every refill?

No. After your first fill is approved, subsequent refills don't require a new prior authorization — unless you switch from one covered GLP-1 medication to a different one, in which case a new PA is required.

What does a GLP-1 cost under the Medicare Bridge program?

Once approved, your copay is a flat $50 per monthly supply. This cost does not count toward your Part D deductible, coverage gap, or annual out-of-pocket maximum. If you receive Medicare Extra Help (low-income subsidy), that benefit cannot be applied to reduce your Bridge program copay.

How knownwell® can help

At knownwell, our care team and support staff are familiar with the Medicare GLP-1 Bridge process and can guide you through every step — from confirming your eligibility to navigating the PA workflow with your pharmacy. If you're a Medicare patient curious about whether an obesity management medication is right for your care plan, schedule a visit with one of our clinicians today.