Wegovy prior authorization criteria

Last UpdatedMarch 5, 2024

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Attention: Drug Claims Management. All current authorizations for these medications for these members will expire on July 31, 2024. 5mg/46mg. You might also hear it called “preapproval” or “precertification”. Weight Loss Medications FEP Clinical Criteria disease, peripheral artery disease, or coronary heart disease) 2. You can also call Novo Nordisk or check your coverage immediately online, with a form you fill out. Food and Drug Administration (FDA)-approved criteria for use. S. • Wegovy has not been studied in patients with a history of pancreatitis COVERAGE CRITERIA The requested drug will be covered with prior authorization when the following criteria are met: • The patient is 18 years of age or older AND º The patient has completed at least 3 months of therapy with the requested drug at a stable maintenance dose Wegovy. 5 mg, and 1 mg once-weekly dosages are initiation and escalation dosages and are not approved as maintenance dosages for chronic weight management. Fax complete signed and dated forms to CVS/Caremark at 888-836-0730. This policy involves the use of Saxenda and Wegovy. 7 mg. 5mg/46mg once daily. ago. One of the following: 1) Disease is Commercial Formulary Prior Authorization Criteria 8 Adrenocorticotrophic Hormones Last revised: 7/5/2022 Generic Brand HICL GSN Representative NDC CORTICOTROPIN ACTHAR GEL 80 UNIT/ML 2830 006597 63004871001 Prior Authorization Criteria: Length of Authorization: Initial: 1 month Reauthorization: 6 months Initial Review Criteria: WEGOVY ® (semaglutide) injection 2. This is called prior authorization. Patient has at least one weight related comorbid Recommendations for prior authorization (PA) criteria to allow coverage of semaglutide (WEGOVY) for secondary prevention of major CV events will be presented. Liraglutide (Saxenda®) Semaglutide (Wegovy™) Tirzepatide (Zepbound™) Prior authorization (PA) requires your doctor to tell us why you are taking a medication to determine if it will be covered under your pharmacy benefit. It also reduces the risk of a major WEGOVY ® (semaglutide) injection 2. Box 52080 MC 139. Semaglutide (Wegovy) for Weight Loss Prior Authorization Form Florida AIDS Drug Assistance Program Revised December 2023 Instructions: • Fax completed form and documentation to ADAP confidential fax line at 850-412-2680. Patient Information. 5 mg. I filled out the prior auth form from plush care with the EXACT language from my insurance’s pre-approval criteria…BMI, metabolic syndrome, insulin resistance, hyperlipidimia and commitment to lifestyle change. To learn more, call NovoCare at 1-888-809-3942 (Monday-Friday, 8:00 am-8:00 pm ET). 2 Saxenda ® (liraglutide), Xenical® (orlistat), Wegovy (semaglutide), or Adipex-P®/Lomaira™ (phentermine HCl) Lifestyle Modification • Include any weight loss attempts by the patient in the past 3, 6, or 12 months • Document that patient will be concurrently making lifestyle modifications such as a Wegovy (semaglutide) Xenical (orlistat) Zepbound (tirzepatide) *Prior authorization for the brand formulation applies only to formulary exceptions due to being a non-covered medication. You’ll also find information on Step Therapy guidelines on the Pharmacy […] Sort by: Search Comments. 75mg/23mg once daily for 14 days, then increase to 7. . COVERAGE CRITERIA The requested drug will be covered with prior authorization when the following criteria are met: • The patient has completed at least 3 months of therapy with the requested drug at a stable maintenance dose AND WEGOVY ® (semaglutide) injection 2. Updated Qsymia weight loss goal to greater than 3 percent per label and changed initial authorization to 4 months. Ensure all required information is included to avoid delays. Semaglutide (Wegovy™) is a glucagon-like peptide-1 (GLP-1) receptor agonist. Prior Authorization Information ☒ Prior Authorization ☐ Step Therapy ☒ Quality Care Dosing Pharmacy Operations: Tel: 1-800-366-7778 Fax: 1-800-583-6289 Policy last updated 5/2024 POLICY STATEMENT. • For any questions regarding this form, please contact the HIV Medical Team via email at HIVMedicalTeam@flhealth. Phoenix, AZ 85072-2080 Attn. Duration of Approval (DOA): • 1190-A: Initial therapy DOA: 4 months; Continuation of therapy DOA: 12 months. This extra check connects you to the right treatment Wegovy (semaglutide) Xenical (orlistat) Zepbound (tirzepatide) *Prior authorization for the brand formulation applies only to formulary exceptions due to being a non-covered medication. Jun 3, 2024 · The Ozempic prior authorization criteria for weight loss. The criteria for medications that need prior authorization or step therapy are based on current medical information and the recommendations of Blue Cross and BCN’s Pharmacy and Therapeutics Committee, a group of physicians, pharmacists and other experts. Clinical Pharmacy Prior Authorization, Notification and Medical Necessity Requirements - Commercial Inclusion in this list does not indicate a drug is covered by a particular plan. Of note, this policy targets Saxenda , Wegovy, and Zepbound; other glucagon-like peptide-1 agonists which do not carry an FDA-approved indication for weight loss are not targeted in this policy. Fax: 1-877-378-4727. Wegovy is a once-weekly injection of semaglutide, which is a medication that mimics glucagon-like-peptide (GLP-1) in the body. Your healthcare provider will complete the paperwork. For additional information regarding Prior Authorization and Health Case Management 3 days ago · If a prescriber or their designee chooses to submit a paper PA request for anti-obesity drugs by fax or mail, the following must be completed and submitted to ForwardHealth: PA/RF. Mississippi Medicaid covers the following anti-obesity agents, subject to this prior authorization criteria: Preferred: • Contrave – age18 and older • Saxenda – age 12 and older • Wegovy – age 12 and older Non-preferred: • Xenical – age 12 and older The following agents are not covered by Mississippi Medicaid : Qsymia – Apr 11, 2024 · In addition, Medicare may require that people must meet certain criteria to control Wegovy usage, such as: step therapy (use of other treatments in stepwise fashion before use of Wegovy) higher out-of-pockets fees; prior authorization, which involves paperwork your doctor must complete to state your eligibility for treatment. • I checked my coverage, and my insurance plan requires prior authorization for Wegovy®. Please complete the patient portion, and have the prescribing physician complete the. Conveniently submit requests at the point of care through the patient’s electronic health record. ” Depending upon how stringent the criteria are for prior authorization approval with respect to pre-existing cardiovascular disease, coverage may be narrowed. See the FDA announcement for full recommendations. COVERAGE CRITERIA The requested drug will be covered with prior authorization when the following criteria are met: • The patient has completed at least 3 months of therapy with the requested drug at a stable maintenance dose AND Some procedures, tests and prescriptions need prior approval to be sure they’re right for you. FDA Approved Indication(s) Wegovy is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of: • 30 kg/m. to the prescription and. Jul 1, 2023 · Mississippi Medicaid covers the following anti-obesity agents, subject to this prior authorization criteria: Preferred: • Contrave – age18 and older • Saxenda – age 12 and older • Wegovy – age 12 and older Non-preferred: • Xenical – age 12 and older The following agents are not covered by Mississippi Medicaid : Qsymia – VA National Formulary Search: VA Formulary Advisor is a search tool for the VA National Formulary and VA Criteria for Use documents. 31, 2024, Saxenda, Wegovy and Zepbound will have new prior authorization criteria for fully insured large group commercial members. Are overweight and have one weight-related condition such as diabetes, high blood pressure, or high cholesterol. SELECT: A multi-national, double-blind, placebo-controlled, event-driven CV outcomes trial of 17,604 adults with a BMI ≥27 kg/m² and established CVD (prior MI, prior stroke, or PAD) designed to assess superiority of once-weekly Wegovy ® 2. Prior Authorization is recommended for prescription benefit coverage of Saxenda, Wegovy, and Zepbound. 25 mg, 0. For renewal of therapy an initial Tricare prior authorization approval is required. Initial therapy approves for 4 months, renewal approves for 12 months. Off-Label Uses N/A Exclusion Criteria N/A Required Medical Information Diagnosis of prostate cancer. O. Download PDF. If a patient has not lost at least 3% of baseline body weight, discontinue OR escalate the dose to 11. Patients must have pharmacy benefits under their subscriber certificates. Authorization@canadalife. Wegovy carries a boxed warning for risk of thyroid C-cell tumors. Find out if you need a PA and how to request one from your health care provider. Any drug may be subject to other requirements including but not limited to Exclude at Launch and or Review at Launch. I was approved in less than 24 hours. Of note, other glucagon-like peptide-1 agonists which do not carry an FDA-approved indication for weight loss are not targeted in this policy. Their eligibility is narrower than the FDA (on purpose). The Prior Authorization Fax Cover Sheet (F-01176 (09/2022 120 tablets per 25 days* or 360 tablets per 75 days*. Wegovy; Xenical; Initial approval criteria for covered drugs with prior authorization: Patient must meet the age limit indicated in the FDA-approved label of the requested drug AND; Documentation of initiation of or ongoing reduced calorie diet; OR; Documentation of ongoing care of a registered dietitian nutritionist; AND Diagnosis requirements for glucagon-like peptide-1 (GLP-1) agonists: Effective June 1, 2023, Humana will require pharmacies to enter a diagnosis code for a medically accepted indication supplied by the prescriber when processing a prescription claim for a GLP-1 receptor agonist for Humana-covered patients. Understanding the Prior Authorization Criteria. 4 mg is indicated in combination with a reduced calorie diet and increased physical activity: to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with established cardiovascular disease and either obesity or overweight. FDA-approved indications: (3-14) Adipex-P, Contrave, Lomaira, phentermine, Qsymia, Saxenda, Wegovy and Xenical are indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in patients with an initial body mass index (BMI) of: 30 kg/m2 or greater (obese) or. 5 mg/46 mg or 15 mg/92mg therapy? Yes or No This is an unofficial community for people who use or are interested in Wegovy, or other GLP-1 RA medications, for weightloss. 7 mg once-weekly. • 10 mo. 1 through Dec. Patient has at least one weight related comorbid Apr 22, 2024 · cardiovascular disease. Health Care Providers. 5 mL pen* 6125207000D520 M, N, O, or Y 8 pens (4 . Learn how to get coverage for Wegovy™, a prescription medication for weight management, and what prior authorization means. To get prior authorization for Wegovy, you need a valid prescription from a licensed healthcare provider. If the EMR/EHR does not support ePA, you can use one of these vendor portals: CoverMyMeds ePA portal. semaglutide (Wegovy) will be covered on the prescription drug benefit for 4 months when the following criteria are met: department at (800)366-7778 to request a prior authorization/formulary exception verbally. 25 mg/0. 3. Fax the completed form and all clinical documentation to 1-866-240-8123 Or mail the form to: Clinical Services, 120 Fifth Avenue, MC PAPHM-043B, Pittsburgh, PA 15222. For renewal of therapy an initial Tricare prior authorization The Pharmacy Medical Necessity Guidelines below detail coverage criteria for Harvard Pilgrim Health Care and Tufts Health Plan lines of business. Given your high cholesterol and qualifying BMI, there is a possibility for approval, but it heavily depends on your insurance plan's criteria and the I had Express Scripts but changed to Caremark. • Wegovy has not been studied in patients with a history of pancreatitis. Pediatric patients aged ≥ 12 years old SC once weekly following dose escalation schedule: Week 1 through 4: 0. Prior authorization is paperwork requested by your insurance carrier to justify the use of Wegovy®. Beginning on the above date, please To date, both Wegovy and Saxenda are approved to be prescribed for chronic weight management, along with a reduced calorie diet and increased physical activity, in individuals who either: Have a body mass index (BMI) of 30 or higher. 5 mg — Encourage your patients to check in throughout their dose-escalation schedule to assess progress and tolerability After receiving a pre-populated prior authorization from CoverMyMeds®, please complete POLICY STATEMENT. 0. Week 13 through 16: 1. Initial therapy approves for 6 months, renewal approves for 12 months. 4 mg (recommended) or 1. This is an unofficial community for people who use or are interested in Wegovy, or other GLP-1 RA medications, for weightloss. For initial approval, you may have your fail Saxenda first. For renewal of therapy an initial Tricare prior authorization Navigating the prior authorization (PA) process for medications like Wegovy can indeed feel daunting, especially when dealing with specific health insurance providers like United Healthcare. Total daily dose should not exceed 400 mg/day. To get prior authorization for Ozempic, you most likely need to meet the U. I wrote exactly what met the criteria requirements for my insurance which I had all of (high BMI, metabolic syndrome, commitment to lifestyle changes) and it was approved within 24 hours. The maintenance dosage of Wegovy in adults is either 2. Please contact CVS/Caremark at 800-294-5979 with questions regarding the prior authorization process. Fax to: The Canada Life Assurance Company Fax 1-833-204-5809 Attention: Drug Claims Management. Starting in October, members will be required to make lifestyle modifications for at least six months before they’re approved for weight Regulatory Status. 7 mg once weekly. Wegovy is listed on the formulary for my plan as "preferred, with a prior authorization". Supporting documentation, as appropriate. FAX (858)790-7100. NOTE: The prescribing physician (PCP or Specialist) should, in most cases, complete the form. 9/2021 Added Wegovy to criteria. • The patient may attach the completed form. When you request a non-formulary exemption, not only do you have to meet all of the criteria for a prior authorization, but you also have to show why you are not able to use any of the formulary products. They require a BMI of 35 or more AND a comorbidity whereas the FDA only requires a BMI of 27. Evaluate weight loss after 12 weeks of treatment at 7. 85K subscribers in the Semaglutide community. • Wegovy has not been studied in patients with a history of pancreatitis . 5 mg — Encourage your patients to check in throughout their dose-escalation schedule to assess progress and tolerability After receiving a pre-populated prior authorization from CoverMyMeds®, please complete This is an unofficial community for people who use or are interested in Wegovy, or other GLP-1 RA medications, for weightloss. I was approved for continuing med based on loss over a certain percentage. Wegovy ® (semaglutide) injection 2. Message: Attached is a Prior Authorization request form. Will you The maintenance dosage in adults is either 2. In these cases, your doctor can submit a request on your behalf to get that approval. Your provider will submit a prior authorization request. Week 9 through 12: 1 mg. Prior Authorization Submission. Wegovy (semaglutide) Xenical (orlistat) Zepbound (tirzepatide) *Prior authorization for the brand formulation applies only to formulary exceptions due to being a non-covered medication. Wegovy is contraindicated in the following conditions: — A personal or family history of medullary thyroid carcinoma or in patients with multiple endocrine neoplasia syndrome type 2. To reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with type 2 diabetes mellitus and established cardiovascular disease. To qualify for Wegovy, you must meet certain criteria set by your insurance provider. Wait for approval: Cigna will review the prior authorization request and determine whether Wegovy meets their criteria for coverage. Prior authorization (PA) is almost always required for insurance to cover Zepbound (semaglutide). Please provide the physician address as it is required for physician notification. The easiest way to do this is to call your What I found is OptumRx secretively narrows the criteria for WHO is eligible for Wegovy behind the scenes. Shoni-the-money. Subsequently, increase the dosage at 1 or 2 week intervals by increments of 1 mg/kg to 3 mg/kg to achieve optimal clinical response. • Wegovy has not been studied in patients with a history of pancreatitis COVERAGE CRITERIA The requested drug will be covered with prior authorization when the following criteria are met: • The patient is 18 years of age or older AND º The patient has completed at least 3 months of therapy with the requested drug at a stable maintenance dose ANTIOBESITY (Criteria requires additional supporting chart notes): 1. Understanding those requirements in advance is a key step to getting your prior authorization for Zepbound approved. While the specific criteria may vary, here are some common requirements: BMI (Body Mass Index) of 30 or higher, or BMI of 27 or higher with at least one weight-related comorbidity; Documented previous attempts at Prior Authorization Criteria Author: Wegovy Prior Authorization with Quantity Limit TARGET AGENT(S) Wegovy (semaglutide) Brand (generic) GPI Multisource Code Quantity Limit (per day or as listed) Wegovy (semaglutide) 0. After 14 days, increase to 15mg/92mg once daily. Of note, this policy targets Saxenda, Wegovy, and Zepbound; other glucagon-like peptide-1 agonists which do not carry an FDA-approved indication for weight loss are not targeted in this policy. Dec 1, 2022 · Prior Authorization Criteria 2022 PPREF Last Updated: 12/1/2022 1 ABIRATERONE Products Affected • Abiraterone Acetate PA Criteria Criteria Details Indications All Medically-accepted Indications. Plush care prior auth process allows you to draft what should be in it based on your diagnoses. Added Imcivree criteria. Prior A uthorization is recommended for prescription benefit coverage of Saxenda , Wegovy, and Zepbound. Formatting changes. MANUAL GUIDELINES Prior authorization will be required for all current and future dose forms available*. When conditions are met, we will authorize the coverage of Wegovy. 25 mg. Good luck! See the ANTIOBESITY section on page 2 of the Prior Authorization Request Form. Wegovy® (semaglutide) – Expanded indication. gov. 4 mg vs placebo (1:1 randomization) for time to first MACE. Wegovy should be used in addition to a reduced calorie diet and increased physical activity. This won’t show up on the app or in your formularies. P. Plain Language Summary: • The Food and Drug Administration approved a medicine called semaglutide (WEGOVY) for patients with overweight or obesity who also had a history of May 30, 2024 · Step 1: Ask your insurance for their prior authorization criteria for Zepbound. Decisions can happen in minutes or take several days or weeks. ☐ Have tried and failed one of the non-GLP1 weight-loss medications 6 months prior to request ☐ For patients 12–18 years of age, a BMI that is ≥ 140% of the 95th percentile by age and sex ☐ For patients 12–18 years of age, an initial BMI that is ≥ 120% of the 95th percentile by age and sex with 3. 4/2021 Added Imcivree as in scope. 4 mg is an injectable prescription medicine used with a reduced calorie diet and increased physical activity: to reduce the risk of major cardiovascular events such as death, heart attack, or stroke in adults with known heart disease and with either obesity or overweight. or greater (obese), or • 27 kg/m. You can usually find the phone number on the back of your insurance card. 2. The Canada Life Assurance Company Drug Claims Management PO Box 6000 Winnipeg MB R3C 3A5. 1, 2023, Blue Cross Blue Shield of Michigan and Blue Care Network will change the prior authorization approval criteria for our commercial PPO and HMO plans for the following weight loss drugs. Feb 7, 2024 · • Semaglutide (WEGOVY) Criteria revised • Tafamidis (VYNDAMAX and VYNDAQEL) Criteria revised • Erenumab (AIMOVIG) Criteria for chronic migraine and episodic migraine prevention revision revised Pharmacy Benefits Management- Medical Advisory Panel- VISN Pharmacist Executives Volume 3, Issue 1 E - MINUTES January 2024 WEGOVY ® (semaglutide) injection 2. to reduce the risk of major cardiovascular events such as death, heart attack, or stroke in adults with known heart disease and with either obesity or overweight. ePA submission. Box 52150, Phoenix, AZ 85072-9954. Has the patient completed at least 16 weeks of therapy (Saxenda, Contrave), 3 months of therapy at a stable maintenance dose (Wegovy, Zepbound), 6 months of therapy with Xenical, or at least 12 weeks of Qsymia 7. Week 5 through 8: 0. 1-866-684-4477. Prior authorization is recommended for pharmacy benefit coverage of Saxenda. Diagnosis, number of migraine headaches per month, prior therapies tried Age Restrictions 18 years and older Prescriber Restrictions N/A Coverage Duration 1 year Other Criteria Approve if the patient meets the following criteria (A and B): A) Patient has greaterthan or equal to 4 migraine headache days per month (prior to 0. Ozempic is approved to lower blood sugar in adults with type 2 diabetes alongside diet and exercise. Prior Authorization Drug Attachment for Anti-Obesity Drugs form. 25mg/69mg. Return to publications. Nevada Medicaid has updated policy to include coverage of Wegovy for this new indication in recipients who meet required prior authorization criteria in-line with FDA package Don t wegovy prior authorization criteria blue cross blue shield forget that this is a gang crime, and there must be some members who are in a leading position and some in a subordinate position. Cost more than other medications used to treat the same or similar Submit the prior authorization form: Your healthcare provider will submit the completed prior authorization form to Cigna for review. 25 mg Wegovy™ pens, record it in the EHR by checking the “samples given” box — Write prescription for 0. Ozempic is indicated: As an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. All medication-specific criteria, including drug-specific indication, age, and dose for each agent is defined in Table 1 below. This fax machine is located in a secure location as required by HIPAA regulations. or email the form only to: TPharmPA@express-scripts. However, Han Yin hopes that interrogators how to regain weight loss due to aging will not only do enough homework, but also always maintain a Jun 6, 2024 · We’re changing prior authorization criteria For dates of service from Aug. Patient has at least one weight related comorbid Prior authorization (PA) is almost always required for insurance to cover Wegovy (semaglutide). The 0. — A prior serious hypersensitivity reaction to semaglutide or to any of the excipients in Wegovy. All approvals are Sep 21, 2023 · Starting Oct. CLPrior. Begin titration at 25 mg once daily (or less based on range of 1 mg/kg/day to 3 mg/kg/day) given nightly for the first week. Updated Saxenda criteria to allow for coverage for 12 years and older. Mar 22, 2024 · The plans may now cover Wegovy when prescribed to prevent heart attacks and strokes, according to a new policy issued this week from the Centers for Medicare and Medicaid Services. Criteria-Based Consultation Prescribing Program Kaiser Permanente Northwest Region Criteria for Drug Coverage semaglutide (Wegovy) Initiation (new start) criteria in pediatric patients for obesity: Non-formulary. Some insurance plans will require a prior authorization to be completed in order to cover the cost of Wegovy. Many doctors have the Prior authorization is a process used by insurance companies, including Tricare, to determine if a prescribed medication is medically necessary and meets specific criteria for coverage. Unfortunately, this is not a guarantee of coverage. mail it to: Express Scripts, P. My insurance covers Wegovy® My insurance requires prior authorization for Wegovy® Review the section that is relevant to you to learn more about possible next steps and how to save on your Wegovy® (semaglutide) injection prescription. Prior Approval. It helps ensure that the medication is appropriate for the patient's condition and prevents unnecessary costs. Updated references. Had Wegovy in hand within two days drugs. Clinical Services. For certain lines of business, you’ll find the pharmacy guidelines elsewhere: Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, and Tufts Health One Care. December 23, 2022 - Novo Nordisk announced the FDA approval of Wegovy (semaglutide), for chronic weight management in pediatric patients aged 12 years and older with an initial body mass index (BMI) at the 95th percentile or greater for age and sex (obesity). 4 mg is an injectable prescription medicine used with a reduced calorie diet and increased physical activity:. • 1 yr. *The duration of 25 days is used for a 30-day fill period and 75 days is used for a 90-day fill period to allow time for refill processing. Some medications must be reviewed because they may: Only be approved or effective for safely treating specific conditions. Apr 5, 2024 · To see if your insurance company covers Wegovy, call them directly yourself. GLP-1 is a key regulator of weight and blood sugar. For your convenience, there are 3 ways to complete a Prior Authorization request: Mar 28, 2024 · Part D sponsors may consider using prior authorization for these products to ensure they are being used for a medically accepted indication. Surescripts Prior Authorizatio Portal. Wegovy is a GLP Type: Initial Prior Authorization POLICY FDA-APPROVED INDICATIONS Linzess is indicated for the treatment of: • irritable bowel syndrome with constipation (IBS-C) in adults • chronic idiopathic constipation (CIC) in adults • functional constipation (FC) in pediatric patients 6 to 17 years of age COVERAGE CRITERIA Wegovy ® (semaglutide) injection 2. com. wp ga pz wn zr bs so by dq my