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pathway for weight loss medications (Effective July 1, 2026) The Centers for
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Program. This temporary demonstration model expands access<o:p></o:p></span></p>
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central processor to manage prior authorization, claims adjudication,
and payment to pharmacies for the Medicare GLP-1 Bridge.<o:p></o:p></span></p>
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<td style='padding:7.5pt 7.5pt 7.5pt 7.5pt;box-sizing:border-box'>
<p class=MsoNormal align=center style='text-align:center'><span
style='font-size:12.0pt'><a
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style='mso-spacerun:yes'>�</span>\* MERGEFORMAT <span
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<p class=MsoNormal align=center style='text-align:center'><strong
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border-bottom:transparent;border-left:transparent;border-radius: 4px;
border-right:transparent;border-top:transparent;display:inline-block'> Prior
Authorization Form</span></span></span></span></strong><span
style='font-family:"Arial",sans-serif;color:#003660'> <o:p></o:p></span></p>
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style='width:100.0%;mso-cellspacing:0in;mso-yfti-tbllook:1184;mso-padding-alt:
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<td style='padding:0in 0in 0in 0in;box-sizing:border-box'>
<div align=center>
<table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0 width=670
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role=presentation>
<tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes;mso-yfti-lastrow:yes;
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<td width="100%" valign=top style='width:100.0%;padding:0in 0in 0in 0in;
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<table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0
width="100%" style='width:100.0%;mso-cellspacing:0in;mso-yfti-tbllook:
1184;mso-padding-alt:0in 0in 0in 0in;box-sizing:border-box'
role=presentation>
<tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes;mso-yfti-lastrow:yes;
box-sizing:border-box'>
<td style='padding:3.75pt 0in 3.75pt 0in;box-sizing:border-box'>
<table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0
width="100%" style='width:100.0%;mso-cellspacing:0in;mso-yfti-tbllook:
1184;mso-padding-alt:7.5pt 7.5pt 7.5pt 7.5pt;box-sizing:border-box'
role=presentation>
<tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes;mso-yfti-lastrow:
yes;box-sizing:border-box'>
<td style='padding:7.5pt 7.5pt 7.5pt 7.5pt;box-sizing:border-box'>
<div align=center>
<table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0
width="100%" style='width:100.0%;mso-cellspacing:0in;mso-yfti-tbllook:
1184;mso-padding-alt:0in 0in 0in 0in;box-sizing:border-box'
role=presentation>
<tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes;mso-yfti-lastrow:
yes;box-sizing:border-box'>
<td style='border:none;border-top:solid #003660 1.5pt;padding:0in 0in 0in 0in;
box-sizing:border-box'><span style='box-sizing:border-box;
word-break:break-word'>
<p class=MsoNormal style='mso-line-height-alt:.75pt'><span
style='font-size:1.0pt;font-family:"Arial",sans-serif'>
</span></span><span
style='font-size:1.0pt'><o:p></o:p></span></p>
</td>
</tr>
</table>
</div>
</td>
</tr>
</table>
<p class=MsoNormal><span style='font-size:12.0pt;display:none;
mso-hide:all'><o:p> </o:p></span></p>
<table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0
width="100%" style='width:100.0%;mso-cellspacing:0in;mso-yfti-tbllook:
1184;mso-padding-alt:7.5pt 7.5pt 7.5pt 7.5pt;box-sizing:border-box'
role=presentation>
<tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes;mso-yfti-lastrow:
yes;box-sizing:border-box'>
<td width="100%" style='width:100.0%;padding:7.5pt 7.5pt 7.5pt 7.5pt;
box-sizing:border-box'>
<h2 style='margin:0in;line-height:18.0pt;box-sizing:border-box'><span
style='box-sizing:border-box;word-break:break-word'><span
style='font-size:15.0pt;font-family:"Arial",sans-serif;mso-fareast-font-family:
"Times New Roman";color:#3A8DDE'>Program at a glance</span></span><span
style='font-size:15.0pt;font-family:"Arial",sans-serif;mso-fareast-font-family:
"Times New Roman";color:#0068A5'> <o:p></o:p></span></h2>
</td>
</tr>
</table>
<p class=MsoNormal><span style='font-size:12.0pt;display:none;
mso-hide:all'><o:p> </o:p></span></p>
<table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0
width="100%" style='width:100.0%;mso-cellspacing:0in;mso-yfti-tbllook:
1184;mso-padding-alt:7.5pt 7.5pt 7.5pt 7.5pt;box-sizing:border-box;
word-break:break-word' role=presentation>
<tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes;mso-yfti-lastrow:
yes;box-sizing:border-box'>
<td style='padding:7.5pt 7.5pt 7.5pt 7.5pt;box-sizing:border-box'><span
style='box-sizing:border-box;word-break:break-word'>
<div style='margin-left:-15.0pt;box-sizing:border-box'>
<ul style='margin-top:0in' type=disc>
<li class=MsoNormal style='color:black;margin-bottom:9.75pt;
line-height:13.5pt;mso-list:l0 level1 lfo1;tab-stops:list .5in'><strong><span
style='font-size:11.5pt;font-family:"Arial",sans-serif;
color:#003660'>Effective:</span></span></strong><span
style='font-size:11.5pt;font-family:"Arial",sans-serif'> July 1,
2026, through December 31, 2027<o:p></o:p></span></li>
<li class=MsoNormal style='color:black;margin-bottom:9.75pt;
line-height:13.5pt;mso-list:l0 level1 lfo1;tab-stops:list .5in;
box-sizing:border-box'><span style='box-sizing:border-box;
word-break:break-word'><strong style='box-sizing:border-box'><span
style='font-size:11.5pt;font-family:"Arial",sans-serif;
color:#003660'>Covered therapies:</span></span></strong><span
style='font-size:11.5pt;font-family:"Arial",sans-serif'> Wegovy�,
Foundayo�, Zepbound� (KwikPen)<o:p></o:p></span></li>
<li class=MsoNormal style='color:black;margin-bottom:9.75pt;
line-height:13.5pt;mso-list:l0 level1 lfo1;tab-stops:list .5in;
box-sizing:border-box'><span style='box-sizing:border-box;
word-break:break-word'><strong style='box-sizing:border-box'><span
style='font-size:11.5pt;font-family:"Arial",sans-serif;
color:#003660'>Patient cost:</span></span></strong><span
style='font-size:11.5pt;font-family:"Arial",sans-serif'> Flat
$50/month<o:p></o:p></span></li>
<li class=MsoNormal style='color:black;margin-bottom:9.75pt;
line-height:13.5pt;mso-list:l0 level1 lfo1;tab-stops:list .5in;
box-sizing:border-box'><span style='box-sizing:border-box;
word-break:break-word'><strong style='box-sizing:border-box'><span
style='font-size:11.5pt;font-family:"Arial",sans-serif;
color:#003660'>Administration:</span></strong><span
style='font-size:11.5pt;font-family:"Arial",sans-serif;
color:#003660'> </span></span><span style='font-size:11.5pt;
font-family:"Arial",sans-serif'>CMS central processor (not Part
D plans)<o:p></o:p></span></li>
<li class=MsoNormal style='color:black;margin-bottom:9.75pt;
line-height:13.5pt;mso-list:l0 level1 lfo1;tab-stops:list .5in;
box-sizing:border-box'><span style='box-sizing:border-box;
word-break:break-word'><strong style='box-sizing:border-box'><span
style='font-size:11.5pt;font-family:"Arial",sans-serif;
color:#003660'>Purpose:</span></span></strong><span
style='font-size:11.5pt;font-family:"Arial",sans-serif'> Provide
Medicare beneficiaries access to GLP-1 medications for weight
loss who do not have type 2 diabetes, moderate-to-severe
obstructive sleep apnea, or fatty liver disease (NASH).<o:p></o:p></span></li>
</ul>
</div>
</td>
</tr>
</table>
<p class=MsoNormal><span style='font-size:12.0pt;display:none;
mso-hide:all'><o:p> </o:p></span></p>
<table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0
width="100%" style='width:100.0%;mso-cellspacing:0in;mso-yfti-tbllook:
1184;mso-padding-alt:7.5pt 7.5pt 7.5pt 7.5pt;box-sizing:border-box'
role=presentation>
<tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes;mso-yfti-lastrow:
yes;box-sizing:border-box'>
<td style='padding:7.5pt 7.5pt 7.5pt 7.5pt;box-sizing:border-box'>
<div align=center>
<table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0
width="100%" style='width:100.0%;mso-cellspacing:0in;mso-yfti-tbllook:
1184;mso-padding-alt:0in 0in 0in 0in;box-sizing:border-box'
role=presentation>
<tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes;mso-yfti-lastrow:
yes;box-sizing:border-box'>
<td style='border:none;border-top:solid #003660 1.5pt;padding:0in 0in 0in 0in;
box-sizing:border-box'><span style='box-sizing:border-box;
word-break:break-word'>
<p class=MsoNormal style='mso-line-height-alt:.75pt'><span
style='font-size:1.0pt;font-family:"Arial",sans-serif'>
</span></span><span
style='font-size:1.0pt'><o:p></o:p></span></p>
</td>
</tr>
</table>
</div>
</td>
</tr>
</table>
<p class=MsoNormal><span style='font-size:12.0pt;display:none;
mso-hide:all'><o:p> </o:p></span></p>
<table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0
width="100%" style='width:100.0%;mso-cellspacing:0in;mso-yfti-tbllook:
1184;mso-padding-alt:7.5pt 7.5pt 7.5pt 7.5pt;box-sizing:border-box'
role=presentation>
<tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes;mso-yfti-lastrow:
yes;box-sizing:border-box'>
<td width="100%" style='width:100.0%;padding:7.5pt 7.5pt 7.5pt 7.5pt;
box-sizing:border-box'>
<h2 style='margin:0in;line-height:18.0pt;box-sizing:border-box'><span
style='box-sizing:border-box;word-break:break-word'><span
style='font-size:15.0pt;font-family:"Arial",sans-serif;mso-fareast-font-family:
"Times New Roman";color:#3A8DDE'>Provider responsibilities</span></span><span
style='font-size:15.0pt;font-family:"Arial",sans-serif;mso-fareast-font-family:
"Times New Roman";color:#0068A5'><o:p></o:p></span></h2>
</td>
</tr>
</table>
<p class=MsoNormal><span style='font-size:12.0pt;display:none;
mso-hide:all'><o:p> </o:p></span></p>
<table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0
width="100%" style='width:100.0%;mso-cellspacing:0in;mso-yfti-tbllook:
1184;mso-padding-alt:7.5pt 7.5pt 7.5pt 7.5pt;box-sizing:border-box;
word-break:break-word' role=presentation>
<tr style='mso-yfti-irow:0;mso-yfti-firstrow:yes;mso-yfti-lastrow:
yes;box-sizing:border-box'>
<td style='padding:7.5pt 7.5pt 7.5pt 7.5pt;box-sizing:border-box'>
<div style='margin-left:-15.0pt;box-sizing:border-box'>
<ol style='margin-top:0in' start=1 type=1>
<li class=MsoNormal style='color:black;margin-bottom:9.75pt;
line-height:13.5pt;mso-list:l1 level1 lfo2;tab-stops:list .5in'><span
style='font-size:11.5pt;font-family:"Arial",sans-serif'>Identify
appropriate candidates based on BMI and comorbid criteria<o:p></o:p></span></li>
<li class=MsoNormal style='color:black;margin-bottom:9.75pt;
line-height:13.5pt;mso-list:l1 level1 lfo2;tab-stops:list .5in;
box-sizing:border-box'><span style='font-size:11.5pt;font-family:
"Arial",sans-serif'>Prescribe covered therapies and send the
prescription to the pharmacy (prior authorization process can
only be initiated after a rejected claim is processed at the
pharmacy) <o:p></o:p></span></li>
<li class=MsoNormal style='color:black;margin-bottom:9.75pt;
line-height:13.5pt;mso-list:l1 level1 lfo2;tab-stops:list .5in;
box-sizing:border-box'><span style='font-size:11.5pt;font-family:
"Arial",sans-serif'>Wait for a prior authorization request from
the pharmacy<o:p></o:p></span></li>
<li class=MsoNormal style='color:black;margin-bottom:9.75pt;
line-height:13.5pt;mso-list:l1 level1 lfo2;tab-stops:list .5in;
box-sizing:border-box'><span style='font-size:11.5pt;font-family:
"Arial",sans-serif'>Complete and submit the GLP-1 Bridge prior
authorization form to the CMS Bridge central processor (not the
plan)<o:p></o:p></span></li>
<li class=MsoNormal style='color:black;margin-bottom:9.75pt;
line-height:13.5pt;mso-list:l1 level1 lfo2;tab-stops:list .5in;
box-sizing:border-box'><span style='font-size:11.5pt;font-family:
"Arial",sans-serif'>Encourage patients to fill prescriptions at
participating pharmacies<o:p></o:p></span></li>
</ol>
<div style='box-sizing:border-box'>
<p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:
9.75pt;margin-left:.5in;line-height:13.5pt'><span style='font-size:
11.5pt;font-family:"Arial",sans-serif;color:black'> <o:p></o:p></span></p>
</div>
</div>
</td>
</tr>
</table>
<p class=MsoNormal><span style='font-size:12.0pt;display:none;
mso-hide:all'><o:p> </o:p></span></p>
<table class=MsoNormalTable border=0 cellspacing=0 cellpadding=0
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