Simplify GLP-1 Prior Authorization with CoverMyMeds
Struggling with prior authorizations for GLP-1 drugs? Discover how electronic prior authorization with CoverMyMeds can help healthcare teams save time on their prior auths and complete all necessary prior auth request fields.
The rise in popularity of GLP-1 drugs, especially when prescribed for weight loss, has led to an increase in prior authorization requirements.AHA: Addressing Commercial Health Plan Challenges to Ensure Fair Coverage for Patients and Providers This growing trend requires healthcare provider teams to spend more time gathering and submitting supporting documentation to meet prior auth requirements across different payers.
Healthcare teams often face challenges in providing proof of therapy necessity, determining patients’ insurance coverage and completing complex forms. An American Hospital Association report found that medical necessity is one of the most common reasons that prior authorization requests are denied.AHA: Addressing Commercial Health Plan Challenges to Ensure Fair Coverage for Patients and Providers
The prior authorization process is not only time-consuming and frustrating for healthcare teams, but it also creates access and affordability barriers for patients who are waiting for the medications they have been prescribed. The American Medical Association notes that medical necessity can “drive doctors to distraction” due to varying definitions across payers,AMA: 7 prior authorization terms that drive every doctor to distraction making it challenging to navigate the process.
To support the hardworking care teams that deal with this reality every day, we’ve compiled a guide to help simplify the prior auth request process for GLP-1s.
COMMON PAYER REQUIREMENTS FOR GLP-1 DRUG PRIOR AUTHORIZATION
Navigating insurance policies for GLP-1 medications can be a maze. Coverage varies widely, with different health plans requiring a different set of criteria for approval.AJMC, Rising Costs Lead Insurers to Drop Weight Loss Drug Coverage, Further Increasing Patient Burden, Aug. 6, 2024
Some typical requirements when submitting prior auth requests for GLP-1 drugs:SingleCare, Wegovy prior authorization criteria: Blue Cross Blue Shield, Feb. 23, 2024 Zepbound, Prior Authorization Resource Guide
- Document medical necessity thoroughly in the patient's chart, including details on:
- The patient's BMI and/or weight history
- Previous lifestyle modifications like diet and exercise and outcomes
- Obesity-related comorbidities
- Reasons why other treatments have been ineffective
- When renewing a GLP-1 prior authorization request, most plans require documentation of a positive clinical response, such as a certain percentage of weight loss from the baseline weight.
- Review the specific prior authorization criteria for the GLP-1 medication you're prescribing. Requirements can vary by payer and drug.
With real-time access to insurance-specific criteria, CoverMyMeds electronic prior authorization (ePA) platform can help you tailor your submissions to meet each payer’s requirements and make sure you don’t miss any required fields.
Quick Guide to Electronic Prior Authorization Requests with CoverMyMeds
Looking for help completing electronic prior authorization (ePA) requests for any drug and any payer? If you haven’t done one before, you’ve done one wrong or you started and gave up, read this quick guide for healthcare providers and office staff.
COMMON ERRORS WHEN SUBMITTING GLP-1 PRIOR AUTH REQUESTS
The prior auth process for GLP-1 drugs can require a considerable amount of paperwork, including patient histories and specific diagnosis codes, to justify the medical necessity of these drugs.Novo Medlink: PA Submission Process Tips When Prescribing a GLP-1 RA for Type 2 Diabetes This repetitive, manual process can lead to administrative fatigue and errors, potentially causing delays in patient treatment.
Administrative Errors
Even small errors like incorrect billing codes or a misspelled name can result in an automatic denial of a request. Requests can also be denied due to blank fields in the prior auth request, or if the request lacks sufficient information about why the medication or treatment is needed. CoverMyMeds' ePA solutions help minimize these errors by guiding providers through the correct forms to help ensure all necessary fields are completed. This reduces the likelihood of denials due to missing or incorrect information.
When integrated with electronic health records (EHRs,) CoverMyMeds automatically populates the necessary fields, reducing manual entry and minimizing errors. This automation can simplify the prior auth process, allowing prescribers to focus more on patient care and less on paperwork.
Procedural Errors
Insurance plans often require providers to have their patients try and fail certain medications or treatments before they approve the next option. Failing to demonstrate that lower-cost alternatives have been tried and failed can result in a denial.
With integrated real-time prescription benefit (RTPB) technology, CoverMyMeds provides visibility into prior auth requirements at the point of prescribing. This allows providers to see if a prior auth request is needed when prescribing a medication.
CoverMyMeds’ integration with EHRs means the necessary documentation showing that a patient has tried and failed other medications can be processed more quickly and efficiently than phone and fax methods.
Ready to get started using CoverMyMeds for prior authorizations?
Tips For Improving Prior Auth Processes
Tasks related to prior authorizations aren’t going to decrease anytime soon. An American Medical Association (AMA) survey of 1,001 physicians found that, on average, practices completed 43 prior authorization requests (across all therapies) per physician, per week in 2023.2023 AMA prior authorization physician survey
To streamline this process, provider offices consider having a staff member dedicated to handling prior auth requests. This can be particularly important during the first months of the year when insurance plans and formularies change.
Maintaining open communication with pharmacies can also be helpful. Working together, pharmacists and provider teams can identify available GLP-1 options and expedite prior auth requests.
Finally, if a prior auth request is denied, you can appeal. Common reasons for denials include a payer’s decision that the prescription is not medically necessary, lack of documentation that other treatments were attempted or the plan does not cover the medication (resulting in an automatic denial.)Medical News Today, How to appeal Wegovy coverage denial, Sept. 4, 2024 In your appeal, follow the payer’s instructions, providing additional clinical rationale and documentation to support the need for the medication.
HOW PROACTIVE PRIOR AUTH HELPS STAY AHEAD OF DENIALS
As more payers require prior auth for GLP-1 drugs, adopting a proactive prior auth policy can help prescribers. Proactive strategies help maintain clear communication between prescribers, pharmacies and payers, and help ensure thorough documentation for the necessity of the medication.
As part of a proactive strategy, submitting prior auths electronically with CoverMyMeds at the time of prescribing can reduce the time-consuming back-and-forth traditionally associated with manual methods such as phone and fax.
Simplify GLP-1 Prior Auth with CoverMyMeds
As the demand for GLP-1 medications grows, embracing electronic prior authorization is important for navigating the complexities of the prior auth process with confidence and ease. CoverMyMeds is the go-to solution for ePA for more than 950,000 providers.
CoverMyMeds’ solutions work for all drugs, including specialty medications, and all health plans and PBMs, including Medicare Part D and Medicaid. Our digital solutions, including ePA and specialty patient support services, are available at no cost to providers, prescribers and their staff through their preferred EHR workflow or the CoverMyMeds portal.
Beyond simplifying the cumbersome prior authorization process, our expansive suite of tech-enabled solutions, backed by human insight, helps break down some of the most common medication access and affordability challenges faced by patients. Our network connects providers, pharmacies, pharmaceutical companies and payers to help people get the medicine they need to live healthier lives.
Ready to get started using CoverMyMeds for prior authorizations?
For more on electronic prior authorization, read "7 Common Prior Authorization Hurdles and How to Overcome Them" and “Set Up Prior Authorization Notifications to Keep Patients Informed.”
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