Increased clinical review volume: diabetes medications for weight loss

February 1, 2023

TikTok and other social media platforms are driving a surge in claims for diabetes medications promoted as weight loss drugs. Learn about Prime actions to mitigate the increase.

Prime actions regarding recent increased clinical review volume: diabetes medications for weight loss 

Prime is taking actions in response to a surge in prescriptions for certain diabetes medications (GLP1 inhibitors) sometimes used off-label for weight loss. This unprecedented increase in volume is driven by mentions of these medications on social media and general news outlets.

Prime is forecasting a 22% increase in overall volume/costs of clinical reviews in the Commercial book of business for January, 2023, compared to the original forecasted volume/costs, based on data pulled Jan. 27, 2023.

This notable increase in volume is mostly driven by the GLP1 inhibitors being used for weight loss, with these medications accounting for more than 19% of all clinical review volume.

Prime will continue to assess volume/cost impacts through the remainder of 2023 and will likely be making further adjustments to the annual forecast.  In the meantime, Prime has taken several initial actions in response to the increased claim volume.

For background, see Prime’s Jan. 19 email.

Actions to-date 

  • Clinical reviews: Prime established a designated clinical team to work on Formulary Exception (FE) and Prior Authorization (PA) requests for these medications. Based on current formulary criteria, more than 85% of case reviews for the highest volume GLP-1 inhibitors (Mounjaro and Wegovy) result in a denial and there continues to be a significant return on investment for overall trend management.

  • PA message automation: Prime implemented an electronic response to providers who request an electronic Prior Authorization (ePA) form when the drug is prescribed without an FDA label-approved diagnosis. The response notes that the drug is not covered without the diagnosis provided.

  • Network fax: Prime sent this fax to all network pharmacies. The fax provided information on claims processing details and reminded pharmacists of important point-of-sale (POS) messaging regarding dispensing these drugs.

  • POS: Prime updated point point-of-sale (POS) messaging specific to Mounjaro indicating coverage only for Type 2 Diabetes: “T2D only, use Ozempic, Rybelsus, Trulicity, Victoza, or Bydureon.” This applies to NetResults A & F Series formularies.

Additional actions may be put in place to address this issue; more information will be provided if further actions are taken.