U.S. diabetes patients face delays as insurers tighten ozone coverage

Deena Beasley

(Reuters) – Some patients with type 2 diabetes say they are having greater difficulty getting reimbursement for drugs like Ozempic as U.S. insurers impose restrictions aimed at preventing doctors from prescribing the weight-loss drug.

Novo Nordisk confirmed in a recent email that it is subjecting GLP-1 drugs, including Ozempic, to stricter health plan management and is working to minimize disruption to patients with type 2 diabetes. A top executive at the Danish drugmaker said at an investor conference last month that this trend has contributed to a recent decline in U.S. prescriptions. Of 24 people with diabetes contacted by Reuters on Reddit, 13 reported recent problems with their health plans covering Ozempic or Mounjaro, a similar drug marketed by Eli Lilly and Company.

Elizabeth Beddow of Texas said her Blue Cross Blue Shield plan required trying two other drugs before it could pay for Mounjaro, which her doctor prescribed after a Type 2 diabetes diagnosis. Instead, she took Ozempic in March, which caused extreme fatigue and gastrointestinal problems.

In September, Beddow, 57, switched to an older drug, Eli Lilly and Company’s Trulicity, but said her blood sugar levels were still rising. Having to start at a low dose and then work up to a maximum dose using two different drugs was “really hard on my body,” she said. “The irony is that my insurance covers Mounjaro without step therapy on January 1.” U.S. regulators approved Ozempic in 2017 to treat diabetes and Mounjaro in 2022. The drugs, most recently marketed under the brand names Wegovy and Zepbound for weight loss, are designed to mimic a hormone called GLP-1 that regulates blood sugar, slows digestion and suppresses appetite.

Most U.S. health plans cover GLP-1 to treat type 2 diabetes, which if left unchecked can lead to serious complications, including kidney failure and amputation.

The self-injectable drugs had a list price of more than $1,000 a month in the United States, but sales quickly soared into the billions, making the companies among the most valuable in the world. Sales are largely limited only by manufacturing capacity.

“What’s really led to increased concern about prior authorization of GLP-1 drugs for diabetes is the increase in off-label weight loss prescriptions,” said Cody Midlam, director of pharmacy operations at Willis Towers Watson. The company provides consulting services to employers. About benefits.

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

Prior Authorization Roadblock

Some diabetic patients told Reuters that prior authorization, in which doctors need approval from their insurance companies before prescribing drugs, has delayed their ability to start new medications or continue taking medications they have been taking for weeks or even months. Others said insurance companies required them to try other drugs before doctors would allow them to prescribe new ones.

A recent J.P. Morgan survey of U.S. benefit executives found that 74% of large employer health plans require diabetes patients to obtain prior GLP-1 authorization, with the remaining one-third increasing this requirement as they respond to higher costs. As a weight loss tool.

Doctors usually must provide proof of diagnosis and show that other drugs, such as generic metformin, do not adequately control blood sugar or cause intolerable side effects. The average number of weekly Ozempic prescriptions increased 33% from the first to the third quarter of this year, but has since fallen more than 6% to about 431,000, according to the Iqvia Data Science Institute.

Doctors and patients are preparing for changes in January, when individual health plans typically set new coverage terms. “It’s possible that starting on January 1, suddenly something will no longer be covered,” said Dr. Robert Gabay, chief scientific officer of the American Diabetes Association. Cost can also be an issue, especially for patients with high-deductible insurance plans . “Depending on coverage, some people still find it unaffordable. That’s definitely a problem,” Gabe said.

Eli Lilly said in an email that it will continue to help people with type 2 diabetes get Mounjaro, adding that some insurance companies may require confirmation of diagnosis or prior use of diabetes medications.

“Prior authorization has to be done every year…for us doctors, a lot of our time is spent on paperwork. It’s something we all have to do, but it’s a barrier,” Anne Peters said Dr., an endocrinologist at the Keck Medical Center of USC in Los Angeles.

She said it’s important that patients receive prescribed treatments and not stop taking medications because of insurance coverage. If the disease is controlled, she said, there’s a better chance of preventing conditions like heart disease, which ultimately kills most people with diabetes.

“If this was an ideal world, you would start using weight loss-related drugs like GLP-1 as early as possible,” Peters said.

(This story has been corrected to change name in paragraph 10 from “Cory Midlam” to “Cody Midlam”)

(Reporting by Deena Beasley; Editing by Caroline Hummer and Bill Burkrot)

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