How to Improve Odds of PA Approval
The VHAN Pharmacy Team gathered three tips for maximizing likelihood of medication coverage:
1. Adhere to FDA indications: Many payers limit coverage to approved indications. For instance, Ozempic and continuous glucose monitoring will not be covered without diabetes. See chart below for comparison of GLP1 agents.
- Lidocaine patches are often limited to neuropathic pain.
- For older medications with many off-label uses, this can be challenging.
2. Document past trials. Plans often have preferred agents or require “step therapy” (e.g. metformin before GLP1ra). Having clear documentation of past therapies is extremely valuable. Explicitly noting any contraindications (e.g. cannot use phentermine due to hypertension) is also helpful.
3. Highlight non-pharmacologic therapy: prescriptions for semaglutide and tirzepatide products account for a large portion of PA requests. Many of these prescriptions are for weight loss. Almost universally, payers ask about past/ongoing behavioral modification, sometimes even asking about the magnitude of calorie restriction or hours of physical activity per week. Clear documentation of lifestyle changes and provider oversight help prevent additional questions, chart messages and appeals.
Non-pharmacologic therapy (i.e. physical therapy) can also be important for approval of overactive bladder treatments or muscle relaxers.
4. Ensure relevant diagnostics are completed. Payers have similar requirements. Diabetes medications will need A1cs. Weight loss medications will need BMIs. Zepbound for OSA will require a sleep study. Testosterone will require baseline levels. Completing and documenting commonly required diagnostics, labs, etc. can prevent delays and improve quality of PA submission.
