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 shouldnt come to PAR team ID: 1037393
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1. Weight Loss Drug PA ProcessJerilyn Cook, PharmD, BCACPMedication Access and Renewal Center (MARC)
2. Weight Loss Drug PA ProcessPrior authorization reviewNo 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 criteriaPlan exclusion: drug is not on formulary and is not coveredPAR runs test claims on all PA requests to determine if a PA is neededAll plans are different even if the same PBM (Ie: Optum Rx, Caremark, Express Scripts)2Set footer with Insert > Header & Footer
3. Weight Loss Drug PA ProcessCommon criteria:BMI > 30 kg/m2BMI > 27 kg/m2 with weight related comorbidities: hypertension, hyperlipidemia, diabetes, pre-diabetes, OSA, CADPatient has participated in a trial of behavioral modification and dietary restriction (time is usually 3-6 mos)Helpful documentation:Updated labs: A1C, lipid panelAny other medical issues that obesity is contributing toInitial 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 medications3Set footer with Insert > Header & Footer
4. Weight Loss Drug PA ProcessCommon issues we see:Ozempic and Victoza being ordered instead of Wegovy and SaxendaGLP-1s being prescribed for weight lossLacking updated labs (ie A1C, lipid panel), which may be helpful getting approvalIncorrect information given to pateints about coverage with manufacturer couponsWeight loss drugs are a plan exclusion under a lot of plans and are never covered under Medicare Part D and MedicaidCannot use manufacturer savings card with government payers (ie: Mounjaro)4Set footer with Insert > Header & Footer
5. Weight Loss Drug PA ProcessAlternative Options:Most plans cover bupropion, naltrexone and topiramate without requiring a PAPhentermine and the above are all inexpensive with goodrx if neededIf plans cover, they often limit coverage to 3 monthsDaily Topiramate (Trokendi) is not always covered by insurance without a PA and probably wouldn’t be covered for weight loss if a PA is requiredQsymia, Contrave, Wegovy, Saxenda all have manufacturer savings supportXenical alternative = OTC Alli or can use goodrxGovernment paid insurance cannot use manufacturer savings– medicare, Tricare, Medicaid, VA5Set footer with Insert > Header & Footer
6. Weight Loss Drug PA ProcessInsurance CaveatsUCHealth:Both UCHealth plans cover weight loss drugs with a PA approvalCU Exclusive plan – standard criteriaUCHealth 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 6Set footer with Insert > Header & Footer
7. Weight Loss Drug PA ProcessInsurance CaveatsMedicareWeight loss drugs are not coveredGLP-1s are sometimes covered without a PA, we can try test claims if requestedMedicaidWeight loss drugs are not coveredGLP-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 drugsStep therapy: phentermine first, then contrave/qsymia/XenicalCan bypass alternatives with drug interactions/contraindicationsDoes not cover GLP-1s for weight loss - Trulicity AND Bydureon are required before others for type 2 diabetes7Set footer with Insert > Header & Footer
8. Contrave Savings and Support8Set footer with Insert > Header & Footer
9. Qsymia Savings and Support9Set footer with Insert > Header & Footer
10. Saxenda Savings and Support10Set footer with Insert > Header & Footer
11. Wegovy Savings and Support11Set footer with Insert > Header & FooterCurrently Wegovy has temporarily stopped shipments of the 0.25 mg and 0.5 mgExpect to make all dose strengths available towards the end of the yearhttps://www.novonordisk-us.com/products/product-supply-update.html
12. Mounjaro
13. Mounjaro
14. SummaryPrescriptions for Victoza and Ozempic for weight loss are discouragedWe won’t submit if:Drug is a plan exclusion GLP-1 prescribed for weight loss and requires a diagnosis of type 2 diabetesType 2 diabetes definition = A1C > 6.5% We won’t lie Requests for test claims to determine coverage are welcome