Solutions to Guard Your Plan Against Off-Label Ozempic

Top 3 Things You’ll Learn

  • GLP-1 prescriptions are rising for diabetes and for weight loss.
  • Overprescribing of GLP-1s costs employers and their employees with Type 2 diabetes.
  • Enhancements to RxBenefits Protect can protect plans and patients.

Over the past year, GLP-1 drugs like Ozempic®, Trulicity®, and Mounjaro™ have been the newest weight loss trend. At this point, though, they’re a fact of life. But they aren’t technically weight-loss drugs – they were originally developed to treat Type 2 diabetes. However, rapidly slimmed-down celebrities and social media influencers, direct-to-consumer advertising, and telehealth platforms willing to prescribe the drugs off-label have spread the word about their weight-loss benefits. Now, diabetes drugs can comprise a significant percentage of plan spend – last year, Ozempic alone represented 4%-5% of total plan cost for the average client in RxBenefits’ Book of Business.

Those costs are not entirely due to GLP-1s, of course. With the growing diabetic population in the U.S., increased diagnoses during the pandemic, and prescribers turning to more expensive treatments earlier in the process, diabetes has consistently been one of the top drivers of pharmacy spend. Add the on-label prescription of GLP-1s to the off-label prescribing of the same drugs for weight loss, and you’re seeing high costs for employers and low drug supply for diabetes patients.

Employers worried about their own pharmacy budget and about their members who use these drugs to treat their Type 2 diabetes need advanced utilization management to get ahead of pricey, inappropriately prescribed GLP-1 medications.

The benefits – and costs – of the newest wonder drugs

GLP-1s are the newest generation of diabetes drug, mimicking a hormone that encourages the body to secrete insulin and to empty the stomach more slowly. It’s a life-changing way for patients with Type 2 diabetes to keep their blood sugar in check. As a side effect, it can also cause major weight loss. Some GLP-1s in a higher-dose form – Saxenda® and Wegovy® – have even been FDA-approved specifically for weight loss. The problem comes when the lower-dose versions – the ones developed to treat Type 2 diabetes – are the ones prescribed off-label for weight loss.

Increasingly, employers are having to cover price tags of up to $1,000 for drugs that may or may not be appropriately prescribed – it’s estimated that as much as 40% of plan spend on GLP-1s could be due to off-label prescribing. And the explosive popularity of the drugs has led to major shortages, leaving tens of millions of Type 2 diabetic patients at risk of being unable to access their medication. When they’re forced to switch to a potentially less-effective drug, or to ration the drugs they have, the health impact can be serious and lifelong.

Protecting your plan and your members with enhanced clinical management

Employers can’t afford to pay for drugs prescribed inappropriately, and members with Type 2 diabetes can’t afford to go without the appropriately prescribed drugs they need. Protecting them both requires expert utilization management, including programs like prior authorizations (PA), quantity limits, and step therapy.

RxBenefits’ Protect suite of clinical solutions helps employers ensure the safety and necessity of their members’ prescriptions with all those programs and with a new enhancement to take on the rising GLP-1 challenge – Utilization Management for Next Generation Diabetes Drugs.

This expansion to our utilization management solution automatically flags GLP-1 claims – for the lower-dose version of the drugs – for prior authorization, requiring the prescriber to confirm that the prescription is medically necessary and dosed according to FDA guidelines. If not, the PA won’t be approved. And RxBenefits has also expanded our service infrastructure to accommodate the growing number of Type 2 diabetes patients unable to access their drugs and the growing number of PAs required to solve that problem for our clients.

Meet emerging challenges with innovative new solutions

GLP-1s aren’t going anywhere – nor should they, as they’re shown to work well for patients who need them for Type 2 diabetes and for the complications that can come with being overweight. But it’s crucial that diabetes patients be able to access the drugs they need, and it’s crucial that employers know their members and their plan are both protected from the harms that come with inappropriate prescribing.

Every prescription benefits plan can benefit from layers of protection and adding utilization management solutions like RxBenefits Protect – and its new, targeted GLP-1 enhancement – provides the security employers need to feel safe about the health of their plan and the health of their members.

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