To: Client leaders for Commercial/HIM, Pharmacy Directors and Compliance contacts.​​​​​​
 
Impacted: This message targets Commercial/HIM but is relevant to all lines of business

Off-label use of diabetes medications

Prime’s clinical operations team has identified an increase in prescriptions for certain diabetes medications, sometimes used off-label for weight loss. This has resulted in an increase in Formulary Exception (FE) and Prior Authorization (PA) requests for Mounjaro and Ozempic. 

This trend appears to be driven by multiple social media platforms where current users are highlighting their success with these medications for weight loss and providing information on how to easily obtain a prescription from telehealth providers specializing in weight loss. In some cases, the manufacturer is offering a savings card that provides a discount if the individual’s health insurance does not cover the medication. As a result, members and providers are seeking a denied FE or PA.  

The increase in FE and PA requests is creating challenges meeting turn-around times (TAT) due to the unplanned volume and will result in increased charges for Prime’s clients. The amount of fee increases per month will vary by client but could be up to double the amount forecasted for the drugs in question. It’s important to note that the increased cost of FEs and PAs to address this issue would be less than the net cost of prescriptions for these medications if the prescriptions were filled. 

Client-specific reports projecting January FE and PA volume for these drugs will be developed this week and then provided to clients by Prime clinical program managers. 

The actions below are being taken for the Commercial/HIM line of business to mitigate impact to TATs and to ease the financial impact to clients.  

Short-term  

• Prime Clinical Operations is identifying and routing FE and PA requests for Mounjaro and Ozempic to a designated team to mitigate impact to TATs.​​​​​​
• The Prime Provider Relations team within network management is sending a fax blast to pharmacies starting Jan. 19, notifying of potential pharmacy audit risk and advising that Prime is only approving for appropriate diagnosis. The fax will also provide guidance to follow applicable manufacturer’s discount requirements. 
• Point-of-sale (POS) messaging specific to Mounjaro for NetResults A & F Series formularies has been updated, effective Jan. 19, to align with fax blast messaging indicating coverage only for Type 2 Diabetes: “T2D only, use Ozempic, Rybelsus, Trulicity, Victoza, or Bydureon”. Note: Any updates to client custom POS messaging updates would need to be requested. Contact your Prime clinical representative to discuss. 
• Prime has confirmed a coverage denial is not necessary to obtain a discount through the manufacturer’s savings card. Prime recommends that clients communicate to providers that a denial is not necessary to obtain a savings card. 

Mid-term  

• Prime will implement an electronic response to the provider when submitting an ePA when the drug is prescribed without a diabetes diagnosis (E11). The response will indicate that the drug is not covered with the diagnosis provided. This capability will be available on February 8th. The outcomes of this action will be monitored closely and adjustments will be made as required. 

Additional actions may be put in place to address this issue; more information will be provided if further actions are taken.  

If you have questions or input, please contact your client engagement representative. 

To access additional Prime client communications and resources, check out the Prime Client Portal. If you don't have access to the portal, contact your IT administrator to request access, just as you would to access any Prime application.

Prime Therapeutics
2900 Ames Crossing Road
Eagan, MN 55121