I wish this document was full of shortcuts and easy “how-to’s”. PAs are the bane of my staff’s existence. I wish I could make them go away, but I can’t. The best thing I can do is give you advice on gathering all the right information before you begin the process. I’m also pretty good at listening if you want to rage about the unfairness of it all and the amount of time you and your staff will spend on this process. I get it. I wish had the power to change it, but I don’t.
Insurance companies keep moving the goalposts on this process, so I can’t promise that this will always be completely up to date, but when trying to get insurance coverage for these meds, a good rule of thumb is that “more is more”. Get as much of this information as you can in your first note so that you or your staff don’t have to reach out to patients multiple times every time you prescribe one of these medications.
This document is to help you get coverage for the treatment of obesity. Getting coverage for treating type 2 diabetes is often much easier and your staff is likely to already be familiar with that process. You will likely be asked (very early on) if the patient has type 2 diabetes. If they do, you will likely get bumped to a different algorithm (and they will want you to write for one of the peptide medications that is FDA-approved to treat type 2 diabetes). Know before you begin!
Medicare won’t pay for AOMs to treat obesity, but you can sometimes get coverage for the prevention of MACEs in patients with preexisting CVD. It’s a bit of a different conversation than what follows, but with Medicare, don’t focus on obesity – focus on cardiovascular risk reduction.
I wouldn’t even bother trying to get coverage for Ozempic or Mounjaro for patients without a diagnosis of type 2 diabetes. Although you may get one or two a year to go through, eventually a pharmacist or someone analyzing claims will nip it in the bud (as their heads will potentially roll) and coverage will be ripped away. If you want to treat obesity (in the absence of diabetes), prescribe the medications that are FDA-approved for the treatment of obesity: Wegovy, Zepbound, or Saxenda.
Completion of a prior authorization for an anti-obesity medication only makes sense if the payor has existing antiobesity medications in its formulary. PAs typically cost employers $60-$100 a pop, so if the patient knows they don’t have coverage for these medications (it’s super easy for them to find out by checking their formulary), we don’t submit them. This just has the downstream effect of raising healthcare costs without providing any increase in value and that doesn’t settle well with me!
Also, prepare to do PAs over and over again for each patient. Oftentimes, you have to repeat the prior authorization every time you escalate the dose, so keeping a spreadsheet of what box you checked for each patient can be helpful.
Aside from the obvious (patient demographics, insurance information), have the following information handy when you begin the PA process:
Appropriate Diagnosis Code:
E66.3 (Overweight, BMI 25-29.9)
E66.811 (Obesity, class 1: BMI 30-34.9)
E66.812 (Obesity, class 2: BMI 35-39.9)
E66.813 (Obesity, class 3: BMI ≥ 40)
Z Codes: Adults:
Z68.25 – BMI 25.0-25.9
Z68.26 – BMI 26.0-26.9
Z68.27 – BMI 27.0-27.9
Z68.28 – BMI 28.0-28.9
Z68.29 – BMI 29.0-29.9
Z68.30 – BMI 30.0-30.9
Z68.31 – BMI 31.0-31.9
Z68.32 – BMI 32.0-32.9
Z68.33 – BMI 33.0-33.9
Z68.34 – BMI 34.0-34.9
Z68.35 – BMI 35.0-35.9
Z68.36 – BMI 36.0-36.9
Z68.37 – BMI 37.0-37.9
Z68.38 – BMI 38.0-38.9
Z68.39 – BMI 39.0-39.9
Z68.41 – BMI 40.0-44.9
Z68.42 – BMI 45.0-49.9
Z68.43 – BMI 50.0-59.9
Z68.44 – BMI 60.0-69.9
Z68.45 – BMI ≥ 70
When submitting PAs for AOMs, especially for dose escalations, there is debate in the medical community about whether you should use the obesity class and BMI that applies to the patient RIGHT NOW – or whether you can use their starting weight/BMI.
We use the code for breast cancer even when a patient is in remission from their disease. With obesity being a chronic disease, there is logic to using the codes that represent the diagnosis that prompted the initial treatment, rather than using codes that reflect the improvement of the initial disease.
Oftentimes, the resolution of severe obesity and/or a lowering of BMI below a certain threshold will abruptly discontinue someone’s eligibility for coverage of their AOM. Although I think this is a bunch of nonsense (we don’t discontinue someone’s antihypertensive medication as soon as they get their blood pressure under control taking the medication), oftentimes the way the PA is worded, using those initial obesity class/BMI codes makes it seem as though you are inputting fraudulent data, which I would never recommend!
Use your judgment on this one. It’s good to document both in the chart in case it happens and you want to appeal it, but most of the time, they don’t care and the bean counters are more than happy to rip the drug away once the patient hits some threshold (that may or may not be known to you).
Concomitant and Ongoing Obesity Care:
They will likely ask a question or two about the patients’ previous attempts at weight loss. Sometimes they ask ten questions and they want specific dates and documentation.
Sometimes there is a specified duration of time that they require a lifestyle intervention to be deployed before approving the addition of an anti-obesity medication (usually 6 months). Sometimes they require documentation that this has been done and sometimes they take your word for it.
Here is the wording from a recent BCBS PA: “The prescriber must document the member’s active participation in any type of lifestyle modification activity (working with a coach, tracking food and exercising) for a minimum duration of six months before the prior authorization request. The prescriber will no longer be able to attest to a member’s participation.”
Sometimes they require the patient to “fail” to lose weight with this type of intervention before they will approve the medication and sometimes the patient has to demonstrate a certain amount of weight loss using non-pharmacologic therapy before pharmacotherapy is approved.
We used to keep a spreadsheet regarding which was which, but the goalposts kept moving on this one, so we finally gave up.
** In your note, it’s a good idea to document previous attempts at weight loss, including the name of the intervention (program, clinic, and/or medication), the dates during which the attempt was made, and the results. Ideally, have the patient fill this out in the medical history questionnaire.
Something like this would be really helpful to have:
It’s also a good idea to document in your note how long the patient has been attempting a lifestyle intervention THIS TIME (immediately preceding the visit in which you are documenting your recommendation to begin an anti-obesity medication).
They often won’t approve a GLP-1 if the patient is also taking another AOM. Although this is not a contraindication and those of us who have been practicing for a long time often use combination therapy, being on one AOM often disqualifies patients from getting approval for another one.
Following this, they are likely to ask you to rule out any contraindications to GLP-1s (even though you likely documented these in the chart and thought about them – it’s an easy barrier for them to erect). Put this information into a quick text blurb somewhere your staff can find it easily – or it’s likely they will call the patient to ask, thus generating a lot more questions, or they will look at the standard medical history form and then reach out to you (because very few standard forms ask specifically about thyroid medullary cancer or MEN-2).
Example:
O The patient has no personal or family history of thyroid medullary carcinoma
O The patient has no personal or family history of multiple endocrine neoplasia type 2 (MEN-2)
O The patient is not currently pregnant or nursing and is not actively planning to become pregnant
O The patient does not have any known allergy or hypersensitivity to any GLP-1 medication
O The patient does not have any known contraindications to taking a GLP-1 medication
O The patient’s age is consistent with the FDA-approved indication
Recently, to get approval, many patients have to be concurrently enrolled in a specific online program to get medications approved (Teladoc, Omada, Vida, etc.). If you aren’t employed by the company they are contracted with, you will have to send the patient there for treatment. Yes, it’s unfair (especially as you often aren’t told this until the PA is done – you’ve just done their dirty work for them) but it is what it is.
The American Medical Association has been trying to reduce the burden of PAs for a long time without success. I’ve been speaking to a lot of employers over the past year about obesity treatment and they all seem to love the idea of PAs (I think they are being sold a bill of goods by their brokers and consultants).
In addition to supporting the AMA in its efforts, the Obesity Medicine Association has created a proposed universal PA template for AOMs – in an attempt to standardize the form and keep insurance companies and PBMs from moving the goalposts. Not surprisingly, they have ignored this request and continue to adjust their processes. If you want to read the OMAs proposal, click on the link below or scan the QR code. Maybe with enough pressure, someday, this entire process will be easier, but for now, it’s the Wild West!