US diabetes patients face delays as insurers tighten Ozempic coverage By Reuters – Canada Boosts

(corrects identify in graph 10 to Cody Midlam from Cory Midlam)

By Deena Beasley

(Reuters) -Some sufferers with sort 2 diabetes say they’re having extra problem getting reimbursed for medication like Ozempic as U.S. insurers implement restrictions designed to discourage medical doctors from prescribing the remedy for weight reduction.

Novo Nordisk (NYSE:) confirmed in a current e mail that it’s seeing tighter well being plan administration of GLP-1 medication together with Ozempic and is working to attenuate disruption for sort 2 diabetes sufferers. The pattern has contributed to a current dip in U.S. prescriptions, an govt on the Danish drugmaker mentioned at an investor convention final month. Out of 24 diabetes sufferers contacted by Reuters on Reddit, 13 reported current issues getting their well being plans to cowl Ozempic or Mounjaro, an identical drug bought by Eli Lilly (NYSE:).

Elizabeth Beddow in Texas mentioned her Blue Cross Blue Defend plan required two different medication be tried earlier than it might pay for Mounjaro, which her physician prescribed after a prognosis of sort 2 diabetes. As an alternative, she was prescribed Ozempic in March, which precipitated excessive fatigue and gastrointestinal points.

In September, Beddow, 57, was switched to an older drug, Lilly’s Trulicity, however mentioned her blood sugar ranges are nonetheless rising. Having to begin a low dose earlier than transferring as much as a most dose with two totally different medicines was “really hard on my body,” she mentioned. “Ironically, my insurance covers Mounjaro without step therapy on January 1.” U.S. regulators accredited Ozempic for diabetes in 2017 and Mounjaro in 2022. The medication, extra not too long ago bought beneath the model names Wegovy and Zepbound for weight reduction, are designed to imitate a hormone referred to as GLP-1 to manage blood sugar, gradual digestion and suppress urge for food.

Most U.S. well being plans cowl GLP-1s for sort 2 diabetes, which if uncontrolled can result in severe problems, together with kidney failure and limb amputations.

Gross sales of the self-injected medicines, which have U.S. record costs of over $1,000 a month, shortly soared into the billions, making the businesses among the many world’s most precious. Gross sales have been restricted largely solely by manufacturing capability.

“What’s really resulted in kind of a more heightened focus on prior authorization for the diabetes GLP-1 drugs is the increased volume from off-label prescribing for weight loss,” mentioned Cody Midlam, director in Willis Towers Watson (NASDAQ:)’s pharmacy follow, which advise employers on advantages.

Well being insurers Aetna, UnitedHealth (NYSE:) and Cigna (NYSE:) didn’t reply to requests for remark.

PRIOR AUTHORIZATION ROADBLOCK

Some diabetes sufferers informed Reuters that prior authorization, by which medical doctors want insurer permission earlier than prescribing a medication, had delayed by weeks, and even months, their means to begin a brand new remedy or keep on a drug they’d been taking. Others mentioned insurers required them to attempt different medication earlier than their medical doctors had been allowed to prescribe a more moderen remedy.

A current JP Morgan survey of U.S. advantages executives discovered that 74% of enormous employer-based well being plans required diabetes sufferers to get prior authorization for a GLP-1, and a 3rd of the remainder deliberate so as to add the requirement as they grapple with larger spending on the medicines as weight-loss instruments.

Docs typically have to offer proof of prognosis and doc that different medicines, corresponding to generic metformin, weren’t sufficient to regulate blood sugar or precipitated insupportable uncomfortable side effects. The common variety of weekly Ozempic prescriptions rose 33% between the primary and third quarters of this 12 months, however has since dropped greater than 6% to about 431,000, in accordance with Iqvia Institute for Information Science.

Docs and sufferers are bracing for adjustments in January, when particular person well being plans typically set new protection phrases. “It may be that January 1, all of a sudden something that was covered is no longer,” mentioned Dr. Robert Gabbay, chief science officer on the American Diabetes Affiliation. Price will also be a difficulty, particularly for sufferers who’ve high-deductible insurance coverage. “Depending on the coverage, some people still find it not affordable. That is certainly a problem,” Gabbay mentioned.

Lilly, in an e mail, mentioned it continues to assist folks with sort 2 diabetes entry Mounjaro, including that some insurers could require affirmation of prognosis or prior diabetes remedy use.

“You have to get prior authorization every year … For us physicians, a lot of our time is spent doing paperwork. It is something that we all have to do, but it is a barrier,” mentioned Dr. Anne Peters, an endocrinologist with Keck Drugs of USC in Los Angeles. She mentioned it can be crucial that sufferers keep on a prescribed remedy, and never get switched off a drug due to insurance coverage protection. If the illness is managed, she mentioned, there’s a higher likelihood of stopping issues like coronary heart illness, which is what finally kills most individuals recognized with diabetes.

“If it were an ideal world, you would use drugs like GLP-1s, associated with weight loss, early,” Peters mentioned.