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Welcome  » September 17, 2021 2:39 PM
Program Name: BadgerCare Plus and Medicaid Handbook Area: Pharmacy
09/17/2021  

Prior Authorization : Services Requiring Prior Authorization

Topic #7837

Prior Authorization for Anti-Obesity Drugs

PA requests for the following anti-obesity drugs must be submitted on the Prior Authorization Drug Attachment for Anti-Obesity Drugs form:

  • Benzphetamine
  • Diethylpropion
  • Phendimetrazine
  • Phentermine
  • Contrave
  • Evekeo
  • Qsymia
  • Saxenda
  • Xenical

Anti-obesity drugs are covered for dual eligibles enrolled in a Medicare Part D PDP.

Submitting Prior Authorization Requests for Anti-Obesity Drugs

Prescribers, or their designees, are required to request PA for anti-obesity drugs using one of the following options:

A prescriber, or their designee, should have all PA information completed before calling the DAPO Center to obtain PA.

Prescribers are required to retain a completed copy of the PA form and any supporting documentation.

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
  • Prior Authorization Drug Attachment for Anti-Obesity Drugs form
  • Supporting documentation, as appropriate

The Prior Authorization Fax Cover Sheet is available on the Forms page of the Portal for prescribers or their designee submitting the forms and documentation by fax.

Prescribers are reminded that they are required to complete, sign, and date each PA form when submitting the PA request on paper.

Note: Imcivree has separate PA submission requirements.

Clinical Criteria for Anti-Obesity Drugs (Excluding Imcivree)

Clinical criteria for approval of a PA request for anti-obesity drugs require one of the following:

  • The member is 16 years of age or older and has a BMI greater than or equal to 30.
  • The member is 16 years of age or older, has a BMI greater than or equal to 27 but less than 30 and two or more of the following risk factors:
    • Coronary heart disease
    • Dyslipidemia
    • Hypertension
    • Sleep apnea
    • Type 2 diabetes mellitus
    • The member is 12–17 years of age and has a BMI corresponding to 30 or greater for adults by international cut-offs (Saxenda and Xenical PA requests only). Note: BMI is determined using International Obesity Task Force BMI cut-offs for obesity by sex and age for pediatric patients aged 12 years and older (Cole Criteria).

In addition, all of the following must be true:

  • The member is not pregnant or nursing.
  • The member does not have a history of an eating disorder (for example, anorexia, bulimia, or binge eating disorder).
  • The prescriber has evaluated and determined that the member does not have any medical or medication contraindications to treatment with the anti-obesity drug being requested.
  • For controlled substance anti-obesity drugs, the member does not have a medical history of substance abuse or misuse.
  • The member has participated in a weight loss treatment plan (for example, nutritional counseling, an exercise regimen, or a calorie-restricted diet) in the past six months and will continue to follow the treatment plan while taking an anti-obesity drug.

PA requests for anti-obesity drugs will not be renewed if a member's BMI is below 24.

PA requests for anti-obesity drugs will only be approved for one anti-obesity drug per member. ForwardHealth does not cover treatment with more than one anti-obesity drug.

ForwardHealth does not cover the following:

  • Brand name (that is, innovator) anti-obesity drugs if an FDA-approved generic equivalent is available
  • Any brand name innovator phentermine products
  • OTC anti-obesity drugs
  • Anti-obesity drugs when used for conditions other than weight loss

ForwardHealth will return PA requests for the above-listed drugs as noncovered services.

Initial and Renewal PA Requests for Benzphetamine, Diethylpropion, Phendimetrazine, and Phentermine

If clinical criteria for anti-obesity drugs are met, initial PA requests for benzphetamine, diethylpropion, phendimetrazine, and phentermine will be approved for up to 90 days. If the member meets a weight loss goal of at least 10 pounds of their weight from baseline during the initial 90-day approval, PA may be requested for an additional three months of treatment. The maximum length of continuous drug therapy for benzphetamine, diethylpropion, phendimetrazine, and phentermine is six months.

If the member does not meet a weight loss goal of at least 10 pounds of their weight from baseline during the initial 90-day approval or the member has completed six months of continuous benzphetamine, diethylpropion, phendimetrazine, or phentermine treatment, then the member must wait six months before PA can be requested for any controlled substance anti-obesity drug.

ForwardHealth allows only two weight loss attempts with this group of drugs (benzphetamine, diethylpropion, phendimetrazine, and phentermine) during a member's lifetime. Additional PA requests will not be approved. ForwardHealth will return additional PA requests to the prescriber as noncovered services. Members do not have appeal rights for noncovered services.

Initial and Renewal PA Requests for Contrave

If clinical criteria for anti-obesity drugs are met, initial PA requests for Contrave will be approved for up to 90 days. If the member meets a weight loss goal of at least 5 percent of their weight from baseline, PA may be requested for an additional 180 days of treatment. If the member's weight remains below baseline, a final PA renewal period of 90 days of Contrave may be approved. PA requests for Contrave may be approved for a maximum treatment period of 12 continuous months of drug therapy.

If the member does not meet a weight loss goal of at least 5 percent of their weight from baseline during the initial 90-day approval, the member's weight does not remain below baseline, or the member has completed 12 months of continuous Contrave treatment, then the member must wait six months before PA can be requested for Contrave.

ForwardHealth allows only two weight loss attempts with Contrave during a member's lifetime. Additional PA requests will not be approved. ForwardHealth will return additional PA requests to the prescriber as noncovered services. Members do not have appeal rights for noncovered services.

Initial and Renewal PA Requests for Evekeo

If clinical criteria for anti-obesity drugs are met, initial PA requests for Evekeo will be approved for up to 30 days. The maximum length of continuous drug therapy for Evekeo is one month.

After the member has completed one month of Evekeo treatment, the member must wait six months before PA can be requested for any controlled substance anti-obesity drug.

ForwardHealth allows only two weight loss attempts with Evekeo during a member's lifetime. Additional PA requests will not be approved. ForwardHealth will return additional PA requests to the prescriber as noncovered services. Members do not have appeal rights for noncovered services.

Initial and Renewal PA Requests for Qsymia

If clinical criteria for anti-obesity drugs are met, initial PA requests for Qsymia will be approved for up to 180 days. If the member meets a weight loss goal of at least 5 percent of their weight from baseline, PA may be requested for an additional 180 days of treatment. PA requests for Qsymia may be approved for a maximum treatment period of 12 continuous months of drug therapy.

If the member does not meet a weight loss goal of at least 5 percent of their weight from baseline during the initial six-month approval or the member has completed 12 months of continuous Qsymia treatment, then the member must wait six months before PA can be requested for any controlled substance anti-obesity drug.

ForwardHealth allows only two weight loss attempts with Qsymia during a member's lifetime. Additional PA requests will not be approved. ForwardHealth will return additional PA requests to the prescriber as noncovered services. Members do not have appeal rights for noncovered services.

Initial and Renewal PA Requests for Saxenda

If clinical criteria for anti-obesity drugs are met, initial PA requests for Saxenda will be approved for up to 180 days. If the member meets a weight loss goal of at least 5 percent of their weight from baseline, PA may be requested for an additional 180 days of treatment. PA requests for Saxenda may be approved for up to a maximum treatment period of 12 continuous months of drug therapy.

If the member does not meet a weight loss goal of at least 5 percent of their weight from baseline during the initial 180-day approval or the member has completed 12 months of continuous Saxenda treatment, then the member must wait six months before PA can be requested for Saxenda.

ForwardHealth allows only two weight loss attempts with Saxenda during a member's lifetime. Additional PA requests will not be approved. ForwardHealth will return additional PA requests to the prescriber as noncovered services. Members do not have appeal rights for noncovered services.

Initial and Renewal PA Requests for Xenical

If clinical criteria for anti-obesity drugs are met, initial PA requests for Xenical will be approved for up to 180 days. If the member meets a weight loss goal of at least 10 pounds of their weight from baseline during the first six months of treatment, PA may be requested for an additional 180 days of treatment. If the member's weight remains below baseline, subsequent PA renewal periods for Xenical are a maximum of 180 days. PA requests for Xenical may be approved for a maximum treatment period of 24 continuous months of drug therapy.

If the member does not meet a weight loss goal of at least 10 pounds during the initial 180-day approval, the member's weight does not remain below baseline, or the member has completed 24 months of continuous Xenical treatment, then the member must wait six months before PA can be requested for Xenical.

ForwardHealth allows only two weight loss attempts with Xenical during a member's lifetime. Additional PA requests will not be approved. ForwardHealth will return additional PA requests to the prescriber as noncovered services. Members do not have appeal rights for noncovered services.

Submitting PA Requests for Imcivree

PA requests for Imcivree must be completed, signed, and dated by the prescriber. PA requests for Imcivree must be submitted using Section VI (Clinical Information for Drugs With Specific Criteria Addressed in the ForwardHealth Online Handbook) of the PA/DGA form.

Clinical documentation supporting the use of Imcivree must be submitted with the PA request.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed PA/DGA form and a completed PA/RF to ForwardHealth.

PA requests for Imcivree may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system or calling into the DAPO Center).

Clinical Criteria for Imcivree

Clinical criteria that must be documented for approval of a PA request for Imcivree are all of the following:

  • The prescription is written by an endocrinologist or geneticist or through an endocrinology or genetics consultation.
  • The member's current height, weight, and BMI are documented.
  • One of the following is true:
    • The member is 6–17 years of age and has a current weight greater than or equal to the 95th percentile using growth chart assessments. (Note: An age-appropriate growth chart must be included with the PA request.)
    • The member is 18 years of age or older with a BMI of greater than or equal to 30.
  • The member has obesity due to POMC, PCSK1, or LEPR deficiency confirmed by genetic testing demonstrating variants in POMC, PCSK1, or LEPR genes that are interpreted as pathogenic, likely pathogenic, or of uncertain significance. (Note: A copy of the genetic testing results must be submitted with the PA request.)
  • The prescriber has evaluated the member and determined that the member does not have any medical or medication contraindications to treatment with Imcivree.

A copy of the member's current medical records must be submitted with all PA requests for Imcivree. Medical records must document the member's medical work-up for obesity including complete problem and medication lists.

Per ForwardHealth policy, member use of manufacturer-provided samples or manufacturer patient assistance programs are not considered as previous medication history for any medication PA review. Members who are started on a medication outside ForwardHealth are not exempt from meeting PA criteria (unless specifically noted).

If clinical criteria for Imcivree are met, initial PA requests may be approved for up to 183 days. If the member meets a weight loss goal of at least 5 percent of their weight from baseline or at least 5 percent of their BMI from baseline (for patients with continued growth potential) during the first 183 days of treatment, PA may be requested for an additional 365 days of treatment. If the member's weight or BMI (for patients with continued growth potential) remains at least 5 percent below the member's baseline weight or their BMI, subsequent PA renewal periods for Imcivree are a maximum of 365 days.

 
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