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September 19, 2023

How PBMs Manage the Costs of Ozempic & GLP-1 Drugs

The world of weight loss is always evolving, and a recent trend has caught the attention of many: the use of diabetic drugs, specifically GLP-1 drugs like Ozempic, for shedding the pounds. Originally developed to manage Type 2 diabetes, these drugs have found a new, off-label use in the weight loss arena. But this trend isn’t as straightforward as it might seem. Managing the costs and usage of these drugs is a complex task, and Pharmacy Benefit Managers (PBMs) play a critical role. They work behind the scenes, negotiating with drug manufacturers and pharmacies to keep costs under control, and their responsibilities are growing with the popularity of GLP-1 drugs for weight loss.

The History of GLP-1 Drugs

The first GLP-1 drugs to come on the scene were short-acting options like Byetta, derived from Gila monster saliva and introduced in 2005, and Victoza®, a human-made analog approved in 2010, both originally used for Type 2 diabetes management. The development of long-acting GLP-1 drugs, such as Ozempic, approved in 2017, and Trulicity®, approved in 2014, marked a significant advancement, offering once-weekly injections and expanding the potential uses of these drugs.

The off-label use of Ozempic for weight loss began gaining attention shortly after its approval. While Wegovy is FDA-approved for weight loss, Ozempic is FDA-approved only for diabetes, although it contains the same Semaglutide active ingredient. However, it is not uncommon for prescribers to write medications for off-label use. This trend raises concerns due to potential health risks, economic impact, ethical dilemmas, and lack of regulation, emphasizing the need for careful oversight and responsible management.

Criteria for Using GLP-1 Drugs

GLP-1 drugs are primarily prescribed to people with diabetes who need help managing their blood sugar levels. Typically, patients must also be over a certain weight or have a specific BMI (Body Mass Index) to qualify. Doctors and healthcare providers must carefully evaluate each patient’s medical history, needs, and overall health to determine if GLP-1 drugs are an appropriate treatment. It’s not a one-size-fits-all solution, and using these drugs without meeting the criteria can lead to more harm than good.

In a world where quick fixes are often sought after, the criteria for using GLP-1 drugs are a reminder that responsible medical practice and patient well-being must always come first. Whether for diabetes management or weight loss, these drugs should only be used under the guidance of qualified healthcare professionals who understand the risks and benefits.

Adverse Effects and Impact on the Marketplace

The use of GLP-1 drugs like Ozempic for weight loss isn’t just a matter of bending the rules. It’s a practice that comes with real risks and broader consequences.

1. Negative Side Effects for Non-Diabetic Use

GLP-1 drugs were designed with diabetics in mind, and using them without the proper medical guidance can lead to serious problems. Adverse effects can range from nausea, vomiting, and diarrhea to more severe issues like liver failure and kidney problems. These aren’t minor inconveniences, but life-altering conditions that can require ongoing medical treatment.

2. Impact on the Marketplace and Diabetics

The buzz around GLP-1 drugs for weight loss isn’t just affecting people who misuse them. It’s having a ripple effect across the marketplace, and people with diabetes are feeling the impact. As demand for these drugs grows, prices can soar, making them less accessible to those who genuinely need them for diabetes management. It’s a classic case of supply and demand, but with real human consequences.

And it’s not just about GLP-1 drugs. The spotlight on these medications might be drawing attention away from other essential drugs for diabetes, including insulin. Any shortages or accessibility issues with these alternatives can further complicate the lives of those managing diabetes.

Combating Off-Label Use and PBM’s Role

The off-label use of GLP-1 drugs for weight loss isn’t just a medical concern; it’s a complex issue that requires a coordinated response. From healthcare providers to PBMs, various players are stepping up to address this challenge.

Strategies to Combat Off-Label Use

PBMs combating off-label use of Ozempic requires a coordinated approach that includes education, oversight, and innovative solutions. Healthcare providers are working to educate patients about the proper use of GLP-1 drugs and the risks of off-label use. Health plans are also playing a role by defining coverage for weight loss drugs, making sure that only those who meet the criteria have access.

In addition, GLP utilization programs are now becoming available, offering a targeted approach to managing these drugs. These programs provide guidelines, support, and monitoring to ensure that GLP-1 drugs are used responsibly and effectively.

PBMs’ Responsibility in Managing Costs

Pharmacy benefit managers are on the front lines of this issue, and their role goes beyond just managing costs. They’re working to ensure drug utilization controls are in place, closely monitoring how GLP-1 drugs are prescribed and used. PBMs collaborate with payers and health plan sponsors to promote responsible healthcare and patient safety.

For example, if a PBM includes Ozempic and other GLP-1 drugs on their formulary, they must communicate clearly with payers and sponsors about the choice to provide coverage. Transparency and collaboration are key to ensuring these drugs are accessible to those who need them while preventing misuse.

Helping PBMs Manage Ozempic and Other GLP-1 Drugs

The challenges of managing GLP-1 drugs are complex but not insurmountable. Innovative solutions making a difference include:

Real-Time Data Insights and Automation

Real-time insights can transform the way PBMs handle GLP-1 drugs. Through advanced data analytics, healthcare professionals can have a clear view of the prescription, purchase, use, and refill process of GLP-1 drugs. Automation allows PBMs to quickly identify inefficiencies, revenue leaks, and compliance issues.

Cost Savings and Time Efficiency

Time is money, and tracking customer touchpoints and identifying savings opportunities helps PBMs keep costs in check. Moreover, tech-enabled solutions allow PBMs to be agile and responsive, making quick adjustments that deliver savings to health plans, insurance companies, and other stakeholders.

Collaboration with Payers and Health Plan Sponsors

Collaboration and communication between PBMs, payers, and health plan sponsors build bridges and ensure everyone is on the same page regarding coverage. The option to integrate with GLP utilization programs offers a potential solution for managing GLP-1 drugs holistically.

Meeting the Challenge Head-On

The popularity and rising costs of Ozempic and other GLP-1 drugs are challenging. From the drugs’ off-label use for weight loss to the issues of cost management and compliance, there’s a lot to navigate, but with the right tools, it’s a problem that can be met head-on.

Xevant believes in making data simple so you can solve your biggest challenges. With real-time insights, automation, cost savings, and collaboration tools, we can transform how PBMs handle Ozempic and more GLP-1 drugs. Learn more about how to track trends in utilization better. Embrace innovation and responsibility, and let’s make healthcare better together.

Get more information on Xevant’s advanced technology or try Xevant for free today.

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Sahily Paoline (1365x2048)


Sahily Paoline, Chief Clinical Officer

Sahily is a licensed pharmacist and expert business leader with more than 20 years of experience delivering high-quality clinical care, building and leading organizations, and staffing and motivating teams in the pharmaceutical and digital health industries. Sahily specializes in Clinical Program Management, Pharmacy Practice and Operations, and building and growing business. She is passionate about the use of data and technology in patient care and believes in a holistic approach to healthcare.


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Mitch Searle

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Pete Tantillo

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SVP, Data

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Sahily Paoline

Chief Clinical Officer

Sahily is a licensed pharmacist and expert business leader with more than 20 years of experience delivering high-quality clinical care, building and leading organizations, and staffing and motivating teams in the pharmaceutical and digital health industries. Sahily specializes in Clinical Program Management, Pharmacy Practice and Operations, and building and growing business. She is passionate about the use of data and technology in patient care and believes in a holistic approach to healthcare.
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VP, Services & Corporate Operations

Todd served as an Artillery officer in the U.S. Army before a disability turned his focus to the business world. He’s carried a bag, led multiple sales operations and sales development efforts, and run a sales team in complex selling environments. The son of small business owners, Todd enjoys helping business leaders grow by using proven, repeatable processes. He holds a BS from the United States Military Academy at West Point and an MBA from the Kellogg School of Management at Northwestern University. Todd lives in Nashville with his wife. He spends as much time outside as possible and co-founded a brewery in 2019.  He’d love to tell you the full story over a pint sometime.

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Jeff Weber

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Lindsay Jones

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