Payers crack down on Ozempic prescriptions

Jakob Emerson – a day ago

Some health insurers are cracking down on off-label prescriptions of new weight loss drugs such as Ozempic, The Washington Post reported June 12.

According to the report, Anthem Blue Cross Blue Shield plans have sent about 150 letters to providers in Missouri, New York and North Carolina, warning clinicians about prescribing Ozempic to non-diabetic patients. The letter noted nationwide shortages that have occurred because of an increase in off-label prescriptions, leading to access issues for diabetics.

“The Special Investigations Unit has completed a comprehensive review of your prescription and professional claims,” a letter to a Missouri physician said. The letter said 60 percent of patients prescribed Ozempic lacked “sufficient evidence” of diabetes and that Anthem would refer “suspected inappropriate or fraudulent activity … to the state licensure board, federal and/or state law enforcement,” according to the Post.

Elevance Health, the parent company of 14 Anthem BCBS plans, has previously said it generally does not cover Ozempic for non-diabetic members.

“I do want to make sure people are clear that GLP-1 is [for] both weight loss and diabetes,” Elevance CFO John Gallina told investors in April. “And for weight loss, we do not cover weight loss drugs, with the exception of a few states where it’s required by state law.”

Danish drug manufacturer Novo Nordisk sells semaglutide, a type of GLP-1, under several brand names, including Ozempic and Wegovy. The two medications are nearly identical, but Wegovy is officially approved by the FDA to treat obesity and Ozempic to manage diabetes.

Because of the similarity, the use of Ozempic as a weight loss tool has exploded across social media and among celebrity circles over the last year, leading to demand far greater than the manufacturer anticipated.

Most payers do not cover modern weight loss drugs because they are expensive, but they do usually cover medications meant to treat diabetes. The drugs can cost upward of $10,000 annually without insurance coverage.

The nation’s largest payers told investors in the first quarter that coverage of GLP-1s has been almost entirely constrained to diabetes care. Among employer-sponsored plans, 22 percent said they offered coverage for prescription weight loss drugs in 2022, according to a recent survey.

For patients seeking a prescription for weight loss and to have it be covered by insurance, some physicians have turned to prescribing Ozempic off label, or prescribing an approved drug for an unapproved use.

Sometimes, payers will cover Ozempic for patients who do not have diabetes. If documentation is needed from the payer, the physician can usually provide blood tests that show “poorly regulated blood glucose levels or prediabetes,” BuzzFeed News reported.