GLP-1

If patient has Medicare insurance:

• If they have a BMI of >35 can prescribe with just obesity diagnosis

• If they have a BMI of >30 MUST also have a dx of heart failure w/ reserved ejection fraction, UNCONTROLLED hypertension, CKD stage 3a and above, prediabetes, prev MI, prev stroke, or sx PAD

• If they have a BMI >27 MUST also have a dx of prediabetes, previous MI, previous stroke, or symptomatic PAD

Through Medicare they will have a co-pay of up to $50/ month

If patient has Medicaid insurance:

They must try and fail Ozempic no matter what the condition (diabetes and weight loss)

Medicaid does not want to approve Mounjaro or Zepbound so in order for them to approve it MUST be documented in note that patient has tried and failed semaglutide: over a 1-month period patient did dietary changes, prescription antiemetics, dose adjustment to remediate side effects

They will want patient to try Ozempic first then Wegovy then Mounjaro then Zepbound

For approval for weight loss:

• Patient must have a dx of Moderate to severe OSA

  • Must have a BMI of >35

  • Must be using CPAP nightly, we will have to show proof

  • Must be documented in note that patients are still suffering from excessive daytime sleepiness, reduced sleep related quality of life

• OR patient must have a diagnosis of cardiovascular deat, prev MI, prev stroke, or PAD with symptoms

  • Must be following with a specialist (cardio, neuro)

  • BMI >27

  • For PAD patients must have one of the following:

    • Intermittent claudication with ankle- brachial index less than 0.85 (at rest)

    • A history of peripheral arterial revascularization procedure

    • A hx of amputation due to atherosclerotic disease

  • Patients must also be on a medication treating that diagnosis

• OR patient needs to have a diagnosis of MASH and must have all of the following:

  • Must see a specialist GI or hepatologist

  • Patient must not have significant alcohol use (no more than 1-2 drinks/day)

  • Have a dx of MASH with moderate to advanced liver fibrosis (consistent with stage F2 or F3 fibrosis) as confirmed by one of the following:

    • Liver biopsy within the past 3 years

    • A recent FIB-4 index greater than or equal to 1.3 for beneficiaries less than 65 years of age or greater than 2.0 >65 AND one of the following

    • Liver stiffness measurement by vibration controlled transient elastography (Fibro scan)

    • Magnetic resonance elastography MRE

    • Shear wave elastography SWE

    • Enhanced Liver fibrosis (ELF) score

THIS MUST ALL BE DOCUMENTED IN NOTE, WE WILL HAVE TO SEND COPY OF ALL REPORTS!

If patient has Commercial insurance:

Patient can go either reach out to their insurance to see if it is covered OR they can go to the manufacturer website and put in their info and they will be able to see if they have coverage. 

• Wegovy: go to https://www.wegovy.com/, go to What will I pay?, click on check your coverage 

• Zepbound: go to https://zepbound.lilly.com/weight, in menu (3 lines in left corner) go to “savings options”, under Explore savings options click “not sure”, and then click “check your coverage”