US diabetes patients face delays as insurers tighten Ozempic coverage

[December 12, 2023]  By Deena Beasley

(Reuters) - Some patients with type 2 diabetes say they are having more difficulty getting reimbursed for drugs like Ozempic as U.S. insurers implement restrictions designed to deter doctors from prescribing the medication for weight loss.

Novo Nordisk confirmed in a recent email that it is seeing tighter health plan management of GLP-1 drugs including Ozempic and is working to minimize disruption for type 2 diabetes patients. The trend has contributed to a recent dip in U.S. prescriptions, an executive at the Danish drugmaker said at an investor conference last month. Out of 24 diabetes patients contacted by Reuters on Reddit, 13 reported recent problems getting their health plans to cover Ozempic or Mounjaro, a similar drug sold by Eli Lilly.

Elizabeth Beddow in Texas said her Blue Cross Blue Shield plan required two other drugs be tried before it would pay for Mounjaro, which her doctor prescribed after a diagnosis of type 2 diabetes. Instead, she was prescribed Ozempic in March, which caused extreme fatigue and gastrointestinal issues.

In September, Beddow, 57, was switched to an older drug, Lilly's Trulicity, but said her blood sugar levels are still rising. Having to start a low dose before moving up to a maximum dose with two different medications was "really hard on my body," she said. "Ironically, my insurance covers Mounjaro without step therapy on January 1." U.S. regulators approved Ozempic for diabetes in 2017 and Mounjaro in 2022. The drugs, more recently sold under the brand names Wegovy and Zepbound for weight loss, are designed to mimic a hormone called GLP-1 to regulate blood sugar, slow digestion and suppress appetite.

Most U.S. health plans cover GLP-1s for type 2 diabetes, which if uncontrolled can lead to serious complications, including kidney failure and limb amputations.

Sales of the self-injected medications, which have U.S. list prices of over $1,000 a month, quickly soared into the billions, making the companies among the world's most valuable. Sales have been limited in large part only by manufacturing capacity.

"What's really resulted in kind of a more heightened focus on prior authorization for the diabetes GLP-1 drugs is the increased volume from off-label prescribing for weight loss," said Cory Midlam, director in Willis Towers Watson's pharmacy practice, which advise employers on benefits.

Health insurers Aetna, UnitedHealth and Cigna did not respond to requests for comment.

PRIOR AUTHORIZATION ROADBLOCK

Some diabetes patients told Reuters that prior authorization, in which doctors need insurer permission before prescribing a medicine, had delayed by weeks, or even months, their ability to start a new medication or stay on a drug they had been taking. Others said insurers required them to try other drugs before their doctors were allowed to prescribe a newer medication.

Boxes of Ozempic and Mounjaro, semaglutide and tirzepatide injection drugs used for treating type 2 diabetes and made by Novo Nordisk and Eli Lilly, is seen at a Rock Canyon Pharmacy in Provo, Utah, U.S. March 29, 2023. REUTERS/George Frey/File Photo

A recent JP Morgan survey of U.S. benefits executives found that 74% of large employer-based health plans required diabetes patients to get prior authorization for a GLP-1, and a third of the rest planned to add the requirement as they grapple with higher spending on the medications as weight-loss tools.

Doctors often have to provide evidence of diagnosis and document that other medicines, such as generic metformin, were not adequate to control blood sugar or caused intolerable side effects. The average number of weekly Ozempic prescriptions rose 33% between the first and third quarters of this year, but has since dropped more than 6% to about 431,000, according to Iqvia Institute for Data Science.

Doctors and patients are bracing for changes in January, when individual health plans often set new coverage terms. "It may be that January 1, all of a sudden something that was covered is no longer," said Dr. Robert Gabbay, chief science officer at the American Diabetes Association. Cost can also be an issue, especially for patients who have high-deductible insurance plans. "Depending on the coverage, some people still find it not affordable. That is certainly a problem," Gabbay said.

Lilly, in an email, said it continues to help people with type 2 diabetes access Mounjaro, adding that some insurers may require confirmation of diagnosis or prior diabetes medication use.

"You have to get prior authorization every year ... For us physicians, a lot of our time is spent doing paperwork. It is something that we all have to do, but it is a barrier," said Dr. Anne Peters, an endocrinologist with Keck Medicine of USC in Los Angeles. She said it is important that patients stay on a prescribed treatment, and not get switched off a drug because of insurance coverage. If the disease is controlled, she said, there is a better chance of preventing things like heart disease, which is what eventually kills most people diagnosed with diabetes.

"If it were an ideal world, you would use drugs like GLP-1s, associated with weight loss, early," Peters said.

(Reporting By Deena Beasley; editing by Caroline Humer and Bill Berkrot)

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