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Because this program is not part of the Part D benefit, the copay: Does not apply to the Part D deductible Does not count toward True Out-of-Pocket (TrOOP) costs Does not include Low-Income Subsidy (LIS) support, even for beneficiaries who qualify for LIS Cannot bill $50 copay to other health coverage including Medi-Cal Not eligible for Medicare Prescription Payment Program Prior Authorization: Will be accepted electronically via CoverMyMeds or by fax 1.800.530.2404 using the Medicare GLP-1 Bridge Prior Authorization Request Form

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Pack size:Pack of 1 (Trial Pack)

Epub 2013 Jan 25

Reduced Form