Weight Loss Drug PA Process
The weight loss drug prior authorization (PA) process, including coverage criteria, common issues, alternative options, and helpful documentation. Find out how to navigate insurance requirements for effective weight management.
- Weight Loss
- Drug
- Prior Authorization
- Coverage Criteria
- Insurance
- Common Issues
- Alternative Options
- Documentation
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Weight Loss Drug PA Process Jerilyn Cook, PharmD, BCACP Medication Access and Renewal Center (MARC)
Weight Loss Drug PA Process Prior authorization review No PA required: drug is covered and shouldn t come to PAR team. No PA required but cost is not covered PA required: drug may be covered if the patient meets certain insurance criteria Plan exclusion: drug is not on formulary and is not covered PAR runs test claims on all PA requests to determine if a PA is needed All plans are different even if the same PBM (Ie: Optum Rx, Caremark, Express Scripts) 2 Set footer with Insert > Header & Footer
Weight Loss Drug PA Process Common criteria: BMI > 30 kg/m2 BMI > 27 kg/m2 with weight related comorbidities: hypertension, hyperlipidemia, diabetes, pre- diabetes, OSA, CAD Patient has participated in a trial of behavioral modification and dietary restriction (time is usually 3-6 mos) Helpful documentation: Updated labs: A1C, lipid panel Any other medical issues that obesity is contributing to Initial weight and updates some insurances will only re-authorize if patient has lost a certain percentage of weight (usually 5% after 3 months of stable dose) What has already been tried and how long diet, exercise, other medications 3 Set footer with Insert > Header & Footer
Weight Loss Drug PA Process Common issues we see: Ozempic and Victoza being ordered instead of Wegovy and Saxenda GLP-1s being prescribed for weight loss Lacking updated labs (ie A1C, lipid panel), which may be helpful getting approval Incorrect information given to pateints about coverage with manufacturer coupons Weight loss drugs are a plan exclusion under a lot of plans and are never covered under Medicare Part D and Medicaid Cannot use manufacturer savings card with government payers (ie: Mounjaro) 4 Set footer with Insert > Header & Footer
Weight Loss Drug PA Process Alternative Options: Most plans cover bupropion, naltrexone and topiramate without requiring a PA Phentermine and the above are all inexpensive with goodrx if needed If plans cover, they often limit coverage to 3 months Daily Topiramate (Trokendi) is not always covered by insurance without a PA and probably wouldn t be covered for weight loss if a PA is required Qsymia, Contrave, Wegovy, Saxenda all have manufacturer savings support Xenical alternative = OTC Alli or can use goodrx Government paid insurance cannot use manufacturer savings medicare, Tricare, Medicaid, VA 5 Set footer with Insert > Header & Footer
Weight Loss Drug PA Process Insurance Caveats UCHealth: Both UCHealth plans cover weight loss drugs with a PA approval CU Exclusive plan standard criteria UCHealth Network Plan and UCHealth HD/HAS Plan: (A) Realistic expectations of weight loss (up to 9.6-16% body weight loss possible after at least one year of compliant treatment, in addition to reduced calorie diets, exercise and typically, group or individual counseling) (B) The need for continued calorie reduction and exercise, as able (C) Chronic nature of weight-loss pharmacotherapy (D) Serious safety concerns and common tolerability concerns with the desired agent 6 Set footer with Insert > Header & Footer
Weight Loss Drug PA Process Insurance Caveats Medicare Weight loss drugs are not covered GLP-1s are sometimes covered without a PA, we can try test claims if requested Medicaid Weight loss drugs are not covered GLP-1s are not covered for any diagnosis, but type 2 diabetes (we will only submit with a confirmed diagnosis of type 2 diabetes) If has diagnosis of type 2 diabetes, must have a 3 month trial (or contraindication) to metformin and has to try 2 preferred (Byetta, Trulicity, Victoza) before non-preferred (ozempic, rybelsus, Bydreon Bcise, Mounjaro) Tricare: Covers weight loss drugs Step therapy: phentermine first, then contrave/qsymia/Xenical Can bypass alternatives with drug interactions/contraindications Does not cover GLP-1s for weight loss - Trulicity AND Bydureon are required before others for type 2 diabetes 7 Set footer with Insert > Header & Footer
Contrave Savings and Support 8 Set footer with Insert > Header & Footer
Qsymia Savings and Support 9 Set footer with Insert > Header & Footer
Saxenda Savings and Support 10 Set footer with Insert > Header & Footer
Wegovy Savings and Support Currently Wegovy has temporarily stopped shipments of the 0.25 mg and 0.5 mg Expect to make all dose strengths available towards the end of the year https://www.novonordisk-us.com/products/product-supply-update.html 11 Set footer with Insert > Header & Footer
Summary Prescriptions for Victoza and Ozempic for weight loss are discouraged We won t submit if: Drug is a plan exclusion GLP-1 prescribed for weight loss and requires a diagnosis of type 2 diabetes Type 2 diabetes definition = A1C > 6.5% We won t lie Requests for test claims to determine coverage are welcome
