News & Insights
Introduction
The demand for GLP-1s has grown, with ingredient shortages being reported in two or more countries since September 1st of 2021.
GLP-1 medications are currently FDA approved for the treatment of Type II Diabetes (T2D) and chronic weight management. This includes a significant portion of the U.S. population with approximately 11% of adults having T2D and 39.6% of adults classified as obese.
The 2023 American Diabetes Association Standards of Care recommended a change in the first-line approach to the treatment of T2D to include GLP-1s over metformin for certain individuals. With the heightened demand and cost of GLP-1 medications, employer groups are looking for unique management opportunities for this class of medications.
FDA-approved for Type II Diabetes and weight management, GLP-1s now take precedence over metformin, prompting employers to seek innovative management strategies.
Objective
To identify the impact of an electronic restricted diagnosis claim edit on GLP-1 trend in a mid-sized self-funded employer group.
Methods
A restricted diagnosis (RDX) edit was implemented to ensure use of GLP-1s for T2D (ICD-10 E11) among a 13,000-member self-funded employer.
GLP-1s indicated for weight loss were not covered under the employers benefit.
The RDX edit was implemented into the pharmacy claims adjudication system on October 1st, 2022, and current GLP-1 users were allowed to continue therapy through December 31st, 2022.
Pharmacy and medical claims were retrieved and evaluated for GLP-1 users from Q1 of 2022 to Q3 of 2023. Paid and rejected pharmacy claims were analyzed for off-label use.
Antidiabetic claims (GPI 27*) and medical claims were compiled and aggregated by quarter. T2D diagnosis was confirmed by either a prior pharmacy history of an antidiabetic medication or a documented diagnosis (E11.x) from medical claims.
Paid and rejected antidiabetic medication claims were compared before and after the implementation of the restricted diagnosis edit.
A 13,000-member employer implemented a restricted diagnosis edit for GLP-1s, focusing on Type II Diabetes, excluding coverage for weight loss indications.
The edit was evaluated from October 1, 2022 through Q3 2023, comparing pharmacy and medical claims to assess its impact on off-label use and antidiabetic medication claims.
Findings
A total of 255 GLP-1 utilizers were identified in Q3 of 2023, a 37-member increase from Q3 of 2022 (218 members).
The number of members without a T2D diagnosis receiving GLP-1 prescriptions decreased by 31% from Q1 2022 to Q1 2023.
The majority of GLP-1 utilizers in this employer group were age 40-59 years old.
The RDX edit prevented 120 members from filling a GLP-1 for uses other than T2D from Q4 of 2022 to Q2 of 2023 and saved the plan approximately 5.2% of total annual 2023 drug benefit spend.
Upon review of the medical claims data, 20 members who filled a GLP-1 did not have a diagnosis of T2D. This information was provided to the Pharmacy Networks team for audit and potential retraction of claims.
In Q3 2023, 255 GLP-1 users were identified, with a notable increase from the previous year, while the RDX edit significantly reduced off-label use, saving approximately 5.2% of the total annual 2023 drug benefit spend.
Take Aways
The implementation of an electronic RDX edit for GLP-1 medications at the point of claim adjudication is a successful strategy to ensure appropriate use for T2D.
Post pharmacy audit of the 20 GLP-1 utilizers without a T2D diagnosis resulted in the reversal of pharmacy claims and additional plan savings.
While the utilization of GLP-1s has increased in this employer group, growth appears to be on par with treatment guideline shifts in the American Diabetes Association’s 2023 Standards of Care.
The predominant age range for GLP-1s of 40-59 years old demonstrates consistency with T2D prevalence findings by the CDC.
Overall, employers and PBMs should continue to seek and brainstorm aggressive management strategies that balance member access with the cost of the medication.
Implementing an electronic RDX edit for GLP-1 medications effectively ensures appropriate use for Type II Diabetes, resulting in successful pharmacy audit outcomes and cost savings.