Impacted: National Account clients

Prime Therapeutics (Prime) would like to share important information regarding clinical criteria updates. 

Earlier this year, Wegovy®, a medication known for its effectiveness in weight management, received U.S. Food and Drug Administration (FDA) approval for an expanded indication to reduce the risk of heart attack and stroke in obese or overweight adults with cardiovascular disease. There are a number of expanded indications pending FDA approval for both Wegovy and Zepbound® – an additional GLP-1 agent used for weight loss. These indications include treatment of Non-Alcoholic Steatohepatitis (NASH) and sleep apnea.

Clinical criteria updates effective Nov. 4, 2024
With the approval of these expanded indications, Prime will be updating the clinical criteria for these agents, beginning Nov. 4, 2024 to allow for coverage of these expanded indications, regardless of benefit election for coverage of weight loss agents. 

Members using Wegovy or Zepbound for obesity will continue to be either approved or denied coverage based on the client’s specific benefit election as it pertains to weight loss agents. Prime maintains strict clinical criteria for the approval of all indications for these drug agents. Coverage of these expanded indications will allow Prime to offer comprehensive support to patients with complex health issues.  

Supporting our members
By expanding coverage for these indications, we're not only providing additional support for members, but also aligning with the advancements in medical practice. Providing access to these medications for their new indications can lead to improved member outcomes, reduced long-term healthcare costs and a better overall quality of care.

Prime believes that these updates are crucial for maintaining a forward-thinking and member-centric approach in our coverage policies. 

Questions?
We are committed to providing you with the best possible support. If you have any questions or need further assistance, please don't hesitate to reach out to your account team.