Diabetes drugs for weight loss

February 15, 2023

Update on coverage requests for diabetes medications used for weight loss

Coverage requests for certain diabetes medications (GLP1 inhibitors) are currently lower than the peak volume seen in early January 2023. However, volume remains relatively high. The notable increase in these requests, starting in late 2022, is driven in part by social media messaging on TikTok, Facebook and other platforms.

Requests for coverage primarily involve Commercial members.

See Prime’s Feb. 1 email for a summary of actions Prime is taking to address this issue.

Prime’s actions regarding GLP1 medications 

Prime’s actions have helped stem the increase in coverage requests for GLP1 mediations. A dedicated Prime clinical team is managing Prior Authorization (PA) requests for these medications. Using current formulary criteria, the team is denying the majority of PA requests. There are client costs associated with the PA requests, but these costs are less than the cost of approved prescriptions would be.

Prime’s Fraud, Waste and Abuse (FWA) team continues to identify high-volume pharmacies and prescribers. Currently, the FWA team has launched multiple investigations, which could result in regulatory or contractual actions against these pharmacies and prescribers.

On Feb. 8, Prime resent a network fax to the top-volume pharmacies (100 claims submitted since Jan. 23, 2023).  This fax was previously sent to all network pharmacies. The fax provides information on claims processing details and reminds pharmacists of important point-of-sale (POS) messaging regarding dispensing these drugs.

If you have questions, please contact your Prime client engagement or clinical contact.