Medicare GLP-1 Bridge Program Pre-Screener

1
Patient Information* This field is required.
Name
Date of Birth
Please Select
Please Select
Arthur
Berlon
Campbell
Feliciano
Furdge-White
Human
Zelasko
Provider
2
Do you have Medicare Part D prescription drug coverage?This could be a stand-alone drug plan or part of a Medicare Advantage plan
YESNO/UNSURE
3
Please read and check each statement* This field is required.To continue, please acknowledge each statement above. These acknowledgments confirm that you understand the program requirements, expectations, and limitations before requesting an appointment.
I understand my first visit will focus on instruction and education.
I understand this is ongoing medication management, with follow-up visits every 3 months.
I understand that if I am not enrolled in CCIQ,an InBody scan costs $20, paid at the time of service, when my provider asksfor one.
I understand my medication costs $50 per month at the pharmacy, and this amount does NOT count toward my Medicare drug plan deductible or yearly out-of-pocket limit.
I understand that prior authorization takes time, and I will not receive my medication on the day of my first visit.
I understand I need to stay current with my Medicare Annual Wellness Visit while in the program.
4
Are you currently taking a weight-loss or diabetes medication like Wegovy, Ozempic, Zepbound, Mounjaro, Saxenda, Trulicity, or Foundayo — paid for by your Medicare plan?* This field is required.
Yes
No
Unsure
I'm paying for my GLP-1 out of pocket
5
Do you have type 2 diabetes?* This field is required.
Yes
No
Not sure
6
Do you have sleep apnea (for example, do you use a CPAP at night)?* This field is required.
Yes
No
Not sure
7
Do you have MASH / fatty liver disease with moderate to advanced fibrosis?* This field is required.
Yes
No
Not sure
8
Have you had your Medicare Annual Wellness Visit in the past 12 months?* This field is required.This is the yearly preventive visit covered by Medicare.
Yes
No
Not sure
9
🛑NOT LIKELY TO BE ELIGIBLE🛑

Based on your responses, you are unlikely to qualify for the Medicare GLP-1 Bridge Program. The following responses may affect your eligibility:

You indicated that your Medicare drug plan already covers a GLP-1 medication.

The Bridge Program is intended for individuals who are not already receiving GLP-1 coverage through their Medicare drug plan.

You indicated that you have one or more of the following conditions: Type 2 diabetes, moderate-to-severe OSA (obstructive sleep apnea), or MASH (fatty liver disease).

These conditions are covered through the standard Medicare Part D coverage pathways and are not eligible for the Bridge Program.

Your Annual Wellness Visit is not up to date.

An up-to-date Annual Wellness Visit is required before we can determine your eligibility for the Medicare GLP-1 Bridge Program. Please schedule your Annual Wellness Visit before moving forward.

If you have questions or would like to discuss other treatment options, please call our office at 765-289-1011.
10
🟡POTENTIALLY ELIGIBLE🟡

Based on your responses, you appear to meet the initial pre-screening criteria for the Medicare GLP-1 Bridge Program.

This is not a guarantee of eligibility or approval. Final eligibility is determined by your provider and Medicare during the prior authorization process.

Next Step: Call our office at 765-289-1011 to schedule an appointment.
11
🛑NOT ELIGIBLE🛑

This program is only available to individuals with Medicare Part D prescription drug coverage, either through a stand-alone Part D plan or a Medicare Advantage plan with drug coverage.

If you're unsure of your coverage, call 1-800-MEDICARE (1-800-633-4227) or review your Medicare plan information.
Should be Empty:

🛑NOT LIKELY TO BE ELIGIBLE🛑

🟡POTENTIALLY ELIGIBLE🟡

🛑NOT ELIGIBLE🛑