Will your Pinon Family Practice PCP consider prescribing one of the popular GLP-1 agonists for weight-loss?

Please read our detailed policy below

In short, YES!  Pinon Family Practice (PFP) will consider medication therapy for patients whom we have an existing relationship with, are the designated Primary Care Provider (PCP) for and who are up-do-date on with an Annual Physical, in our office.   PFP will only consider prescribing a medication approved by the FDA and only for a patient that meets the specified criteria for the medication.  

We understand how these medications can be life-changing and we will do what we can to help get you started on and/or continue with your weight-loss journey.  We want to be transparent and explain that we are finding the popular GLP-1 agonists more and more difficult for patients to get these medications for two reasons – insurance coverage issues and there is a national shortage of each of these medications.  We will not prescribe the “active ingredient” of a GLP-1 to a compounding pharmacy as these are not FDA regulated.         

Many of the insurance carriers made changes to their coverage policies January 1, 2024 or even earlier in 2023 at renewal.  Unfortunately, each insurance carrier and even each plan within has different requirements that must be met prior to considering coverage of the medication, if at all.   We have found that if the medication is not an excluded benefit of a policy altogether, the insurance carrier will require a Prior-Authorization (clinical documentation of medical necessity that meets their coverage requirements, sometimes driven an employer) to even consider coverage.  Other carriers have written “weight-loss” coverage completely.  

The one consistent requirement of the insurance carriers’ however is our office must provide an initial as well as ongoing (quarterly), face-to-face visit documentation to consider weight-loss medication therapy.   We are required to document current weight/height, weight goals, lifestyle modifications such as calorie reduction, exercise, behavioral support/nutrition therapy, weight check-in’s etc….  These “weight-loss” visits will be with your PFP provider and are subject to copay and deductible as per your insurance policy guidelines.  If your insurance does not cover weight-loss/obesity, you will be 100% responsible for the visit.      

 Due to the barriers described above, we will require your assistance and completion of the following 2 steps.  We respectfully ask that you contact your insurance carrier and request your policy details for the questions listed below.  You will find the telephone number on the back of your insurance card for member services or, even a number specifically for pharmacy benefits.

  Step 1 -

1.      Does my plan provide coverage for weight-loss medication therapy? 

2.      Does this coverage include any of the three GLP-1 medications:  Wegovy, Zepbound or Saxenda?  

a.      Does my policy provide better coverage for one over another?

 3.      If my plan does cover Wegovy, Zepbound of Saxenda, what will my out-of-pocket expense be?

a.       It is important to note that even when “covered” these can include a very high monthly cost.  We do not want to go through the lengthy process below if the cost will not work into your budget.   

 4.      If my plan does cover any of the three medications, am I required to first fail another weight-loss medication (aka, step-therapy) before you will cover?

a.      Have you met those requirements?  Have you discussed this with your provider?

 5.      If my plan does cover a medication, what medical criteria must I meet?  For example, do I have to have a specific body mass index (BMI), a specific medical condition, a specific lab value and/or am I required to have completed nutrition therapy or behavioral support and have documented lifestyle modifications?

a.      Have you met those requirements?   Have those been discussed/documented with PFP.

6.      Will Prior-Authorization (PA) be required?   Will you provide me with the specific prior-authorization requirements for coverage?  (ask that they email you or direct you to their website for the form that will be required) 

a.      Please complete the details to the best of your ability to assist in the Prior-Authorization approval process, if applicable. 

b.      Schedule a follow-up visit with your provider (this can be done via telemedicine) to discuss the form and coverage requirements or, alternate options.  This will need to be done before we can submit it to your insurance and/or via CoverMyMeds (a third-party PA company used by most major insurance carriers).  

c.       Please note:  if for any reason the insurance denies coverage after the PA has been submitted, we will not appeal their decision.  You will need to meet with your PFP provider to discuss alternative out-of-pocket options that may be available. 

     7.      If my plan does not cover one of these three medications, what weight-loss medications are covered and are there specific requirements that must be met, such as those previously noted?    Please follow the same steps for any alternative medication they might cover.

 **Please note:  We cannot and will not alter a medical record, diagnostic value or provide inaccurate or false information for any reason.   

Step 2 –

Due to the national shortages and daily (even hourly) changes of pharmacy stock and delivery schedules, please contact your pharmacy before contacting our office to send in/release your prescription.   Our office is not equipped to manage or keep track of the pharmacies stock, their delivery schedules, those that take your insurance and those that don’t etc….

 After you have confirmed that your pharmacy of choice has the medication and the prescribed dose in stock, please send a portal message (this is our preferred method and will provide the fastest response) with the pharmacy details including major cross streets and phone number.   If you do not have the patient portal, please leave our staff a detailed message by calling 303-948-2676 and at the announcement message, dial extension #140.  Please provide us with your name, date of birth, and the pharmacy name, cross streets, and phone number and repeat the medication name and dose requested to avoid any confusion. 

 **Please note:  if Wegovy is unavailable for example and your insurance will cover Zepbound, they will make us go through the same Prior-Authorization process for each medication we attempt. 

 

Below are the medications and doses should you need the detail:

Saxenda – daily administration

.06 mg daily/week 1

1.2 mg daily/week 2

1.8 mg daily/week 3

2.4 mg daily/week 4

3.0 mg daily/week 5 – ongoing

 

Wegovy – weekly administration

.25 mg weekly/weeks 1-4

.50 mg weekly/weeks 5-8

1.7  mg weekly/weeks 9-12

2.4  mg weekly/weeks 13 – ongoing

 

Zepbound – weekly administration

.25 mg weekly/weeks 1-4

.50 mg weekly/weeks 5-8

7.5 mg weekly/weeks 9-12

10.0 mg weekly/weeks 13-16

12.5 mg weekly/weeks 17-20

15.0 mg weekly/weeks 21 – ongoing