When Milwaukee-based Ascension Wisconsin’s pharmacy team switched on centralized prior authorizations for GLP-1 prescriptions at a few small primary care clinics, the volume was so heavy that the team turned it off two weeks later and immediately hired two people.
“The volume with the Bridge program was enough to convince our healthcare system to hire more staff to support it,” said Chris Weber, MD, medical director of bariatric services at Ascension Wisconsin, during a panel at Becker’s Fall Chief Pharmacy Officer Summit.
Dr. Weber and Diana Isaacs, PharmD, an endocrine clinical pharmacy specialist at Cleveland-based Cleveland Clinic, described how their systems have handled the Medicare GLP-1 Bridge program since it opened July 1. At both systems, pharmacy has carried much of the load.
Getting prescriptions to the system’s own pharmacies
Cleveland Clinic started preparing June 3, with pharmacy, informatics, primary care and bariatrics at the table. One early lesson was that prescriptions sent to outside pharmacies did not always go smoothly. Dr. Isaacs said the system now pulls reports on where Bridge prescriptions are going, so it can target outreach to clinicians who send them elsewhere.
The system has also sent letters to patients, and Epic now defaults Bridge prescriptions to Cleveland Clinic’s home delivery pharmacy. Patients often pick an outside pharmacy for insurance reasons, but “for Bridge, it’s not going through insurance, so that shouldn’t matter,” Dr. Isaacs said. Her pharmacy team handles the prior authorizations and makes sure prescriptions route to the program.
Ascension Wisconsin’s split runs the other way. Dr. Weber estimated that about 5% of its Bridge prescriptions go to Ascension pharmacies, partly because the system has not promoted the option. That matters because prescriptions sent to Ascension pharmacies go to a centralized team. Prescriptions sent outside fall to individual clinics, where prior authorizations are “a little rockier” for staff who do not handle them often. Promoting the internal pharmacies is on his to-do list, he said.
Cleveland Clinic is also moving all prior authorizations under its pharmacy team. Previously, each department handled its own.
Letting the EHR do the screening
Dr. Weber said anything added to primary care’s workload “has got to take as close to zero extra seconds as possible.”
At Cleveland Clinic, typing “bridge” while ordering brings up smart sets with each drug’s titration schedule, the BMI and comorbidity criteria and the exclusions. Dr. Isaacs said that helps keep prescriptions that will not qualify, such as those for patients with Type 2 diabetes, from being sent at all. The system’s AI scribe tool also suggests an obesity diagnosis when one is missing from the chart, which clinicians can accept or reject. Patients need that diagnosis to qualify.
Ascension Wisconsin uses an optional best practice alert that appears when a patient qualifies. Dr. Weber said clinicians can also find eligible patients with plain-language EHR searches, such as patients with a BMI of 27 or higher and prediabetes in a given ZIP code.
The criteria are harder than they look
The criteria look straightforward, but both panelists said clinicians had more questions than expected. Dr. Isaacs cited questions such as what counts as resistant hypertension and whether a patient whose blood pressure is controlled on medication qualifies. Dr. Weber said some patients arrived July 1 expecting the drug for $50 a month, only to learn they did not qualify. That required “some service recovery,” he said.
He also said leaders should not read eligibility as care. “Coverage isn’t treatment,” he said. Cleveland Clinic uses monthly, often virtual, shared medical appointments and embedded clinical pharmacists for titration and follow-up.
Leadership attention moves the numbers
Dr. Weber described what happened when a C-suite leader at Ascension Wisconsin made obesity diagnoses a tracked metric. The share of patients with obesity documented on their problem list rose from single digits to 80% to 90% within about six months. When priorities changed and the directive went away, the numbers drifted back down.
“When there’s a directive from a decision maker, it changes behavior,” he said.
The end date
The program is set to end Dec. 31, 2027. Dr. Isaacs said clinicians need to be upfront with patients about that. Cleveland Clinic hopes to show real-world outcomes, such as persistence and improvements in blood pressure, lipids and kidney function, that strengthen the case for continued coverage.
“We don’t know what will happen in 2028,” she said. “But we are hopeful that we will be able to demonstrate outcomes.”
