In Part 1, Wegovy and Zepbound based on clinical study results were compared to each other as much as possible. Part 2 will discuss how these clinical studies will affect patients in daily living.
Happy New Year!?
It’s that time of the year. Pharmacy’s most hated month starts in January. Just as your pharmacist and pharmacy technicians how they are doing in January. The start of the new year means the start of a new pharmacy benefits plan (insurance) for many people.
You might have experienced an increase in co-pay, the introduction of high deductibles on essential medications (like insulin), requiring prior authorization again, and/or formulation change.
If you are one of the patients who were administering Ozempic or Mounjaro for weight-loss off-label indication, highly likely you will be denied coverage regardless of prior authorization.
Ozempic being introduced in social media as the “gold standard” of weight-loss medication, Novo Nordisk acted swiftly to get Ozempic approved for weight-loss medication and succeeded. Semaglutide is now either Ozempic (indicated for type 2 diabetes) or Wegovy (indicated for weight loss). Same for Mounjaro, which is indicated for treatment/management of type 2 diabetes, but Eli Lilly also got approved tirzepatide as either Mounjaro or Zepbound (indicated for weight loss).
So, if you did not have a history of type 2 diabetes in 2023, but were using Ozempic or Mounjaro to lose weight, the pharmacy will tell you either denied, prior authorization required or not in the formulary. Even with prior authorization, you will get rejected. The pharmacist will call the doctor to get an alternative to Ozempic or Mounjaro, and insurance may want your doctor to prescribe Wegovy or Zepbound instead.
Take my Wegovy or Zepbound Prescription!
The pharmacy will gladly take the prescription and fill the Wegovy or Zepbound from your doctor. Well, not really. Everyone knows the insurance does not like to pay. That is why the insurance has deductibles, high premiums, and/or different tiers of medication coverage to minimize paying out to you and keep your hard-earned money for themselves.
Here is the deal. When you go to the pharmacy, unless you work for Novo Nordisk or Eli Lilly, the pharmacy will likely tell you that the prescription requires prior authorization or is not covered. If not covered, the only option is to pay cash or use GoodRx discount coupon.
If the pharmacy tells you prior authorization, essentially, your doctor has to submit a paper form to your insurance to convince the insurance that you need Wegovy or Zepbound.
How Can My Doctor Convince the Insurance?
Simple. If your doctor says “Yes” to all the following questions about you, you will have a higher chance of getting the insurance to approve Wegovy/Zepbound for weight loss.
Are you an adult defined as 18 years or older?
Is your BMI 27 kg/m2 or higher? or Is your BMI 30 kg/m2 or higher?
Do you have any co-morbid conditions like (heart disease, diabetes, high cholesterol, etc)? → Might be ok with “No”
If you have diabetes, are you taking any medications other than GLP-1 agonists to control blood sugar? → Might be ok with “No”
Do you have good behavior modification habits (diet and exercise)?
Are you willing to follow a reduced calorie intake by at least 500 kcal/day?
Are you willing to exercise 150 minutes/week?
No history or family history of thyroid cancer or thyroid diseases?
Are these questions sound familiar? They should because all those are from clinical studies and patient criteria. This is how clinical studies can impact you in the real world. As of now, there are no Wegovy or Zepbound that were conducted in non-overweight or non-obese participants. So, if you do not fit the criteria above, the insurance will likely not cover Wegovy/Zepbound for you to lose weight. Of course, the insurance can ask more questions than listed above, for those are the starting point. At a minimum, if you fit all the questions above and need Wegovy/Zepbound for weight loss, the insurance will cover it. But please be aware your co-pay may be different than Ozempic or Mounjaro's co-pay from 2023.
What if my BMI is 25 kg/m2?
The FDA considers a BMI of 25 kg/m2 to be overweight. If your doctor explains eloquently the reason why you need Wegovy/Zepbound to the insurance, the insurance may cover the medication for use for weight loss. This is where scientific discussion occurs and must provide evidence that you will benefit from the treatment.
What’s next?
If the insurance is nice to you, it may approve the medication. So, you go to the pharmacy to pick up and realize the co-pay is extremely high. The insurance is saying, we covered the Wegovy/Zepbound, but didn’t tell you that it will be expensive. This is an insurance way of discouraging people to not to picking up the medication and passive-aggressively asking you to lose weight in another way.
Conclusion
The clinical study design is the backbone of insurance coverage. The insurance does not want to take risks on new medications because there isn’t enough safety data to calculate the cost-benefit. Therefore, insurance uses clinical study design and parameters to evaluate and forecast the cost and benefit to maximize the profit. After all, the insurance is there to make money, not to help you out when sick. As a pharmacist, I always ask patients to avoid new medications for at least 3 to 5 years until more robust efficacy and safety data are available. Medications with positive long-term efficacy and safety data are crucial to one health. More data, better decision-making for one’s health. Of course, if the new medication is the only available treatment option, the benefits should outweigh the costs. Please keep in mind that there is always an out-of-pocket option available and ultimately, everyone must make decision based on available information or ignoring the available information.
Thank you for your time.
-ProoSt!