Weight Loss Drug PA Process Jerilyn Cook, PharmD,

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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 shouldnt come to PAR team. No PA required but

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01
Weight Loss Drug PA Process Jerilyn Cook, PharmD, BCACP
Medication Access and Renewal Center (MARC)<br>
02
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>
03
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>