How To Streamline GLP-1 Prior Authorization and Increase Access to FDA-approved Drugs For Obesity

Prior authorizations create administrative burdens for hospitals nationwide, and new weight loss medications—known as GLP-1 receptor agonists—exacerbate existing revenue cycle management challenges. This is especially true in today’s rural healthcare facilities and critical access hospitals where profound healthcare staffing shortages persist.

Still, Wegovy, Ozempic, and other FDA-approved for drugs for obesity continue to gain attention for their effectiveness. So it’s not surprising that prescriptions for these weight loss medications increased by 300% between 2020 and 2022, according to a new report release by Trilliant Health in September 2023. In fact, healthcare providers in the United States wrote more than 9 million prescriptions for Ozempic, Wegovy, and similar drugs in the last three months of 2022, the report found.

GLP-1 Medicare coverage

Some experts hope the impact of these weight loss mediations will be lower costs and improved outcomes. However, preliminary data remains unclear. According to an October 2024 report from the Congressional Budget Office (CBO), authorizing coverage of anti-obesity medications (AOM) in Medicare would increase federal spending, on net, by about $35 billion from 2026 to 2034. Beyond 2034, net federal costs to the Medicare program would probably be lower on a per-user basis than in the first decade because the CBO expects that the cost of the anti-obesity medication will fall over time and the savings from improved health will grow over time.

Currently, GLP-1 Medicare guidelines permit  GLP-1 Medicare coverage through Part D plans, but only for drugs that the FDA has approved for type 2 diabetes and cardiovascular disease. As of August 2024, this list of FDA-approved drugs for obesity includes Ozempic, Mounjaro, Rybelsus, and Wegovy. Of note: Medicare Part D plans do not cover GLP-1 drugs when used for weight loss. Interestingly, the Trilliant Health report found that just over half of patients taking weight loss medications have a history of type 2 diabetes, meaning almost half of users are likely taking the anti-obesity medications for weight loss.

GLP-1 prior authorization

As patients continue to express interest in weight loss medications, the question is this: How can healthcare organizations streamline GLP-1 prior authorizations?

Each payer and plan is different. This means GLP1- coverage and GLP-1 prior authorization requirements between payers and plans may vary significantly. And requirements could—and do—change over time. In addition, even if the anti-obesity medication is covered, patients may still face varying levels of cost sharing or formulary restrictions with greater patient financial responsibility occurring when drugs are placed on higher tiers within the formulary.

Here are some strategies that can help ease the administrative burden associated with GLP-1 prior authorization on today’s busy healthcare providers and potentially increase patient access to these weight loss medications:

1. Educate providers on insurance coverage requirements. This requires tracking the organization’s most prevalent insurer’s GLP-1 coverage criteria for these anti-obesity medications and then ensuring providers document each patient’s diagnosis and treatment plan appropriately. Documentation of medical necessity is paramount, and providers must also be mindful of insurer coverage limits for prescriptions. Creating checklists by weight loss medication and insurer can help providers streamline efficiency with GLP-1 prior authorizations and prescribe alternative anti-obesity medications that a payer is more likely to cover, thereby reducing costly and time-consuming rework. Note that noncompliance (e.g., prescribing AOMs without examining and diagnosing patients or submitting false or misleading documentation to support coverage) can result in insurance fraud allegations, loss of credentials, loss of a medical license, and other ramifications.

2. Implement processes to review and respond to insurer requests for documentation. This should include processes to ensure the information each provider submits is accurate and aligns with medical record documentation.

3. Provide patient support. If a patient does not satisfy the GLP-1 coverage criteria but wants to move forward with taking the weight loss medication and paying for it themselves, providers should document these discussions. However, they can also help empower patients navigate other lower-cost options. For example, patients may be able to apply for exceptions to gain access to a drug not on their plan’s formulary or lower their cost sharing if the drug is on a high tier. Being able to answer patients’ questions with empathy and understanding is critical.

4. Consider gold card programs to bypass prior authorization requirements for preferred providers. For example, United Healthcare recently launched its gold card program designed to modernize the prior authorization process and simplify the healthcare experience for consumers and healthcare professionals.

Weight loss medication: Looking ahead

Having a strategy in place to address GLP-1 prior authorizations for GLP-1 medications can help healthcare organizations streamline operational efficiency while also meeting—and exceeding—patient expectations. Learn how Inland RCM can help.