Medicare GLP-1 Bridge Program Interest Form
Starting July 1, 2026, Medicare is offering a temporary GLP-1 Bridge program that may help eligible Medicare Part D patients access certain weight-management medications for a $50 monthly copay. This form helps Skippack Pharmacy collect basic information so we can help you understand the next steps. Completing this form does not guarantee approval or coverage. To be considered for the program, your healthcare provider must prescribe an eligible medication and complete the required prior authorization when requested. Medicare currently lists Foundayo® tablet, Wegovy® injection or tablet, and Zepbound® KwikPen® only as included medications. Please complete the form below, and our team will follow up with you.
Let's learn a little more about you.
We may know some of you, we may not know others but we'd love to know everyone who we have the opportunity to serve & thus need some information to get you started.
Patient status with Skippack Pharmacy
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I have used Skippack Pharmacy for prescriptions
I have used Skippack Pharmacy for vaccines or testing
I am new to Skippack Pharmacy
How did you hear about us?
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My Doctor
A Friend / Family Member / Referred by Another Patient on Weight Loss
Skippack Pharmacy Email
Facebook
Instagram
Google
ChatGPT
Nextdoor
Website
A News Story (Fox29, NBC, ABC, CBS)
Skippack Village (Post/Newsletter)
A News Website (NP Now, PV Now, Wiss Now)
I Am A Patient of Skippack Pharmacy
My Pharmacy Told Me About You
Other
Patient's Name
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First Name
Last Name
Gender
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Female
Male
Other
Date of Birth
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-
Month
-
Day
Year
Date
Patient Address (if you will be requesting the product be shipped to you, please ensure the address below is your mailing address)
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
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Preferably non-comcast.net email addresses as Comcast has been filtering our emails or sending them to spam. If it is a comcast.net email address & you sign up, if you see the THANK YOU page after submitting, thats the same information that would get emailed to you.
Cell Phone Number
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-
Area Code
Phone Number
Please list the name and city of the DOCTOR/PROVIDER who may prescribe this medication for you.
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Medicare Information
Please provide your Medicare prescription coverage information so our team can better understand which next steps may apply to you. This form does not guarantee approval, but it helps Skippack Pharmacy review your information and guide you through the process.
Do you currently have Medicare prescription drug coverage?
Yes, I have a standalone Medicare Part D plan
Yes, I have a Medicare Advantage plan with drug coverage
Yes, I have a Special Needs plan
Yes, I have an employer/union Medicare drug plan
No
Other
Optional upload fields (Medicare card or prescription drug card):
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Medication Interest
Please let us know which GLP-1 medication you are interested in or currently prescribed. The Medicare GLP-1 Bridge only includes certain medications, so this information helps us determine whether your request may fit the program guidelines.
Which medication are you interested in or currently prescribed?
Foundayo® tablet
Wegovy® injection
Wegovy® tablet
Zepbound® KwikPen®
Not sure
Other
Any other information you would like to add to help us help you?
If nothing, leave blank & move on to the last line.
I understand that completing this form does not guarantee eligibility, approval, coverage, or medication availability. I understand that my healthcare provider must prescribe an eligible medication and complete the required Medicare GLP-1 Bridge prior authorization. Skippack Pharmacy does not determine whether I qualify. If approved, I understand that I will be responsible for a $50 copay for each one-month supply. The $50 copay is separate from my regular Medicare Part D benefits and does not count toward my Part D deductible or out-of-pocket maximum. I authorize Skippack Pharmacy to review the information provided and contact me with instructions regarding the next steps.
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