Insurance companies are taking a hard position against doctors who prescribe Ozempic, a diabetes medication that has found proven in weight loss.
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Insurance companies have been sending out letters to doctors and hospitals regarding the dangers of off-label drug use in recent weeks.
What Insurance Companies Are Worried About
When Anthem Blue Cross Blue Shield wrote a letter to a doctor in Missouri, it read, “one of investigating team has come up with a comprehensive review of your prescription and their claims.” Despite FDA approval, almost 60% of Ozempic patients did not have sufficient diabetes proof.
The insurance company stressed that patients might be put at danger if the medicine was prescribed for other diseases, and that they would report any suspected improper or fraudulent conduct to the proper authorities.
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It appears that a conflict over the use of new medications for the treatment of obesity is inevitable, as similar letters were addressed to practitioners in both New York and North Carolina.
The Growth of GLPs and the Insurance Industry’s Predicament
Patients are going crazy for GLPs (Glucagon-like peptide 1) medications like Ozempic, and the pharmaceutical industry is treating them like gold. However, insurance companies have a dilemma due to the high costs of these medications and the enormous patient population that could benefit from them.
Insurers are being stricter on off-label medicines right now. Insurers are reluctant to cover weight reduction treatments like Ozempic because of the risk of financial loss, but this could change if more research shows that losing weight has wider health advantages.
In the latter part of this summer, researchers plan to release the findings of the first large study on the subject.
The Problem with Unapproved Use of Drugs
Semaglutide, the active ingredient in both Ozempic and Wegovy, is approved for the treatment of obesity, however Ozempic is solely licenced for the treatment of diabetes.
Ozempic has been prescribed off-label for the treatment of obesity by doctors due to the absence of insurance reimbursement for weight-loss drugs.
Obesity Medicine Association President Angela Fitch, who has seen several of Anthem’s letters, finds them to be unnecessary.
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Fitch concludes that semaglutide in either the Wegovy or Ozempic formulations is clinically indistinguishable. She claims that doctors who prescribe the medicine are not engaging in any dishonesty.
How Insurance Companies React to Shortages
In a statement, Anthem’s plan administrator, Elevance Health, said that less than 150 doctors received the messages. The insurance company stated that Ozempic is typically not covered until the individual has been diagnosed with diabetes and has exhausted all other treatment options.
Still, doctors can legally prescribe it. The increased demand caused by off-label prescribing was also mentioned in the letters, as was a statewide shortage of the medicine.
The trade group America’s Health Insurance Plans is worried about the costs and adverse effects of GLPs. They noted that research on the effects of these drugs on diseases linked to obesity is ongoing, including heart disease and diabetes.
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Increased Interest in GLPs
Barbara Senich, 66, from North Carolina, and Rhondalynne Ware, 59, from Texas, have both benefited greatly from Ozempic’s extraordinary results. Both of them were suffered due to obesity that was impacting their lives while they have used all the treatments available before knowing about Ozempic.
When I was younger, I often felt like I had reached the end of the road and there was no turning back. Senich, a former pharmaceutical executive whose battle with weight began in fourth grade, said, “But now I feel empowered and in control.“
Ware, an accountant, said, “It’s not like anything else I’ve have ever used.“Ware doesn’t have prediabetes, but Senich does, which is covered by her insurance.
Eventually, Ware was prescribed Mounjaro, a GLP medicine licenced for diabetes but also used off-label to treat obesity, after her insurance stopped covering Ozempic.
For Ware, this was a game-changer, especially considering that Eli Lilly offered a manufacturer rebate that reduced the cost to $25 per month. However, it was difficult for her to locate pharmacies that honoured the discount.
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“During my visits to chain pharmacy along with mom-and-pop stores even outside of state,” Ware said.“
Wegovy and other weight-loss medicines were unexpectedly included in the coverage of some health plans, such as the Teacher Retirement System of Texas.
According to a letter addressed to the Obesity Medicine Association last month, the system has detected an increase in the use of these drugs among its members, despite the fact that they are not included as a benefit.
The letter said that “it was not TRS’s intention to provide coverage for weight loss and anti-obesity drugs,” adding that doing so “would require TRS to consider the costs of such medications when determining premiums for all plan participants.”
Even though obesity was officially labelled a disorder by the American Medical Association in 2013, its treatment is still driven by prejudice. Many insurance policies do not cover treatments for obesity since it is considered a preventable disease that can be managed with diet, exercise, and willpower.
Some health plans will cover generic lisinopril (GLP) for unapproved applications, but most will not.
Dr. Jaime Almandoz, medical director of UT Southwestern Medical Centre in Dallas, said the “eat less, move enough” approach is not beneficial for the average individual seeking considerable and sustainable weight loss.
Dr. Almandoz noted that last year, anyone with commercial insurance could utilise the Eli Lilly coupon for Mounjaro, regardless of diabetes.
“led to a potential increase in over the counter off-label prescriptions,” as mentioned by Dr. Almandoz, because of this and a research completed this summer showing significant weight loss among obese individuals without diabetes who used tirzepatide.
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Insurers are increasingly requiring patients to exhaust less expensive weight-loss options before agreeing to cover GLP medicines, which is creating administrative burdens for doctors.
Doctor Taher Modarressi (Hamilton Cardiology Associates physician) of New Jersey predicts a crash despite having never faced such severe criteria. He thinks doctors should give patients the best care possible, and that includes recommending GL.
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