Saxenda Prior Authorization Form. Coverage criteria the requested medication will be covered with prior authorization when the. Prescribers may refer to the forms page of the.
Saxenda® (liraglutide) Injection 3 mg Coverage
For saxenda request for chronic weight management in pediatrics, approve. Web how to get medical necessity. Web prior authorization request form for liraglutide 3 mg injection (saxenda) 6. Current bmi ≥ 40 kg/m. Web once you have verified your patient’s benefits, then you can initiate the prior authorization process. Has the patient completed at least 16 weeks of therapy (saxenda, contrave) or 3 months of therapy at a stable maintenance dose (wegovy)? Of note, this policy targets saxenda and wegovy; Coverage criteria the requested medication will be covered with prior authorization when the. Sponsor id # phone #: Web • saxenda has not been studied in patients with a history of pancreatitis.
December 09, 2019 urac accredited pharmacy benefit management, expires. Initial coverage (*if approved, initial coverage will be for 18 weeks) liraglutide (saxenda) may be eligible for coverage when. Web step please complete patient and physician information (please print): Yes or no if yes to question 1 and. Web initial authorization • one of the following: Current bmi ≥ 40 kg/m. Web prior authorization request form for liraglutide 3 mg injection (saxenda) 6. Sponsor id # phone #: December 09, 2019 urac accredited pharmacy benefit management, expires. Download and print the form for your drug. Web coverage request letter coverage request letter are you frustrated because saxenda® (liraglutide) injection 3 mg is not covered by your employer’s prescription benefit plan?.
