Weight Loss Drug PA Process Jerilyn Cook, PharmD,
Description: 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 shouldnt come to PAR team. No PA required but
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slide1. Weight Loss Drug PA Process Jerilyn Cook, PharmD, BCACP
Medication Access and Renewal Center (MARC)<br>
slide2. 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<br>
slide3. 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<br>
slide4. 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<br>
slide5. 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<br>
slide6. 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<br>
slide7. 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<br>
slide8. Contrave Savings and Support 8 Set footer with Insert > Header & Footer<br>
slide9. Qsymia Savings and Support 9 Set footer with Insert > Header & Footer<br>
slide10. Saxenda Savings and Support 10 Set footer with Insert > Header & Footer<br>
slide11. Wegovy Savings and Support 11 Set footer with Insert > Header & Footer 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<br>
slide12. Mounjaro<br>
slide13. Mounjaro<br>
slide14. 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<br>
Medication Access and Renewal Center (MARC)<br>
slide2. 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<br>
slide3. 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<br>
slide4. 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<br>
slide5. 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<br>
slide6. 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<br>
slide7. 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<br>
slide8. Contrave Savings and Support 8 Set footer with Insert > Header & Footer<br>
slide9. Qsymia Savings and Support 9 Set footer with Insert > Header & Footer<br>
slide10. Saxenda Savings and Support 10 Set footer with Insert > Header & Footer<br>
slide11. Wegovy Savings and Support 11 Set footer with Insert > Header & Footer 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<br>
slide12. Mounjaro<br>
slide13. Mounjaro<br>
slide14. 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<br>