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A4: For a member to qualify, a provider must submit a prior authorization request that attests the member meets the following criteria: The member is prescribed the requested drug to reduce excess body weight and maintain weight reduction in combination with current and ongoing lifestyle modification including structured nutrition and physical activity consistent with the applicable FDA approved label, AND The member is at least eighteen (18) years of age and has a BMI greater than or equal to thirty-five (≥35) at the time of initiation of GLP-1 therapy, or The member is at least eighteen (18) years of age and has a BMI greater than or equal to thirty (≥30) at the time of initiating GLP-1 therapy with 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, or The member is at least eighteen (18) years of age and has a BMI greater than or equal to twenty-seven (≥27) at the time of initiating GLP-1 therapy with a diagnosis of one or more of the following: (A) pre-diabetes (as defined by American Diabetes Association guidelines), (B) previous myocardial infarction, (C) previous stroke, or (D) symptomatic peripheral artery disease Q5: Who will serve as the central processor for the Medicare GLP-1 Bridge responsible for managing prior authorization, claims adjudication, and payment to pharmacies
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