This short form helps us determine whether the Medicare GLP-1 Bridge consultation pathway may be appropriate for you.

This form does not determine final eligibility, guarantee medication access, or replace a medical evaluation. Final eligibility depends on Medicare GLP-1 Bridge rules, clinical criteria, documentation, and the prior authorization process.

Please answer the questions below so we can direct you to the correct next step.

Please answer all questions below before submitting.

Do you have Medicare Part B or a Medicare Advantage plan that includes medical coverage for provider visits? *

Yes

No

I'm not sure

Do you have Medicare Part D prescription drug coverage, either through a standalone Part D plan or a Medicare Advantage plan with drug coverage? *

Yes

No

I'm not sure

Are you seeking evaluation for GLP-1 therapy for weight management? *

Yes

No, I currently use a GLP-1 medication for diabetes or another diagnosis

I'm not sure

Are you currently located in Georgia and seeking care as a Georgia patient? *

Yes

No

Are you 18 or older? *

Yes

No

First Name *

Last Name *

Phone *

Email *

Preferred contact Method *

Best Time to contact *

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