Weight Loss Drug PA Process Jerilyn Cook, PharmD,

Transcript:Weight Loss Drug PA Process Jerilyn Cook, PharmD,:
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 >