A ‘Wonder Drug’ Comes Under Scrutiny from Payers

On paper, Ozempic (semaglutide) is indicated to help improve glycemic control in adults with type 2 diabetes and reduce risk of cardiovascular events in patients with type 2 diabetes and established cardiovascular disease. Its acclaim in the media and popular culture, however, is much more focused on its corresponding weight loss benefits. Consequently, off-label prescriptions have soared—to the extent that payers are now scrutinizing prescriptions written for patients who are not diabetic. As noted in an article published online by Becker’s Payer Issues, many insurers decline to cover weight loss drugs except in states where it’s required by law, but obviously are much more likely to cover medications to treat patients with diabetes. So, writing for Ozempic has become something of a workaround for many. The Washington Postreported that Anthem Blue Cross Blue Shield is sending letters to providers in some states, asking them to refrain from prescribing Ozempic off-label because some patients with diabetes are already having difficulty getting their on-label prescriptions filled. Urgent care providers who may be writing such prescriptions should be aware that future prescriptions may not be covered, depending on the payer and state regulations.