Due to the substantial increase in use of certain glucagon-like peptide-1 (GLP-1) products for weight loss purposes, which are not approved by the Food and Drug Administration (FDA), the utilization management strategy for these drugs is changing from a step therapy to a prior authorization (PA) requirement. Off-label use of these medications has led to drug shortages and made it difficult for some diabetics to be able to obtain their needed medication. This update will help ensure availability of these GLP-1 products for members who require them to control their Type II diabetes. The update will also aid in decreasing inappropriate use of these medications.
For members new to therapy, the PA requirement goes into effect February 13, 2023. For existing members that use these medications, the PA requirement goes into effect April 3, 2023. Members will be notified of these changes via letter to be mailed in early February.
What this means for you
On the previously mentioned dates, Ozempic®, Rybelsus®, Trulicity®, Victoza® and Mounjaro® will require PA. The requirement will verify that these medications are being used for the FDA approved indication of Type II diabetes. Providers must submit clinical documentation to establish the member’s Type II diabetes diagnosis, as well as attestation that the member will not be using the medications for the sole purpose of weight loss. Additionally, PA approval will require documentation of trial and failure (a minimum of 90-day supply) of metformin or any metformin combination products.
Note: This information does not apply to Marketplace (Exchange or Affordable Care Act) plans.
If you have any questions on this bulletin, contact Provider Education at 803-264-4730 or Provider.Education@bcbssc.com.