skip to main content
Company Information  |  Language Assistance

BLUE VISIONSM

News for Employer Groups

Nov. 10, 2023

BCBSIL’s Approach to Managing GLP-1 Agonist Medications

Applies to all groups
The Challenge: Glucagon-like peptide-1 agonists (GLP-1) are a class of medications approved to help improve blood sugar control for people who have type 2 diabetes. In addition to the positive effects on diabetes, this category of drugs also results in weight loss. This discovery led to new GLP-1 medications that have an indication for chronic weight management.

When weight loss success stories were shared on social media, there was a surge in demand and use, not only from people that have type 2 diabetes, but also those seeking weight loss. Because most of the social media stories focused on the GLP-1 drugs used for diabetes, this led people to discuss the positive benefits of these specific medications by name.

Ensuring coverage and minimizing barriers: Blue Cross and Blue Shield of Illinois has continued to focus on ensuring coverage and minimizing barriers for patients with type 2 diabetes, while also supporting weight loss coverage as a custom benefit option. This allows groups to make decision that best align with their strategy. The continued rise in utilization of GLP-1s has generated the need for ongoing and evolving clinical management strategies and new ways to improve the member experience, such as using data to help qualifying members avoid the prior authorization (PA) process altogether. The summary below outlines the evolution of strategies to best support use of GLP-1 medications – from initiation of prior authorization to incorporating new technology to leverage integrated claims data and more.

Automation at the Pharmacy Counter: Integration of medical claims and prescription claims data are being used in automation logic with network pharmacies. This data connects medical diagnoses with prescription claims at the time of processing to qualify members who meet clinical‑program criteria and remove them from any prior authorization review requirements.
  • Starting in June 2023, this ‘smart’ automation technology was put in place to review requests for the GLP-1 drugs used for diabetes. Now, when there is a documented medical diagnosis of type 2 diabetes and claims history for diabetes medications, members meet the PA criteria and the prescriber does not need to submit a PA request at all. This review happens behind the scenes and members don’t need to contact their doctor or BCBSIL.

Clinical Program Management: Beginning Jan. 1, 2023, the GLP‑1 Agonists PA program was added as a standard PA program with dispensing limits to manage appropriate GLP-1 use for patients with type 2 diabetes. Note: some self-insured employers may not have selected this PA program for their members. Prior to the PA program implementation, some drug lists managed these medications under a Step Therapy (ST) program with dispensing limits. At the time of implementation, system edits and PA criteria were in place to ensure that those members already using a GLP-1 agonists could continue therapy without interruption (also called continuation of therapy).
  • Effective Nov. 1, 2023: Prescriber attestation of a type 2 diabetes diagnosis is no longer accepted on the PA approval form. Provider chart notes are now required to show history and documentation of a type 2 diabetes diagnosis to encourage safe and cost-effective GLP-1 drug use.

    • Starting on or after Jan 1, 2024, the PA criteria will be updated to remove continuation of therapy for members using a GLP-1 drug but have not gone through the GLP-1 PA program. Members without a type 2 diabetes diagnosis in medical claims or prescription history for other diabetes drugs will work with their prescribers to submit documentation of the missing information to meet prior authorization criteria. The implementation of the claims integration PA automation described above was necessary to have in place before moving forward with this change in the GLP-1 PA program.

    • Targeted letters will be sent to impacted members 60 days before their plan’s effective date alerting them that their doctor will need to submit the required documentation with their PA request.

    • However, this does not apply for members with an existing PA in place today for a GLP-1 medicine used for diabetes. All approved PAs will remain in effect until the expiration date, and our PA notification alerts will remind members and prescribers about those dates in advance.

    • For employers that have elected to cover weight loss medications, it is important to remember that those drugs are managed independently from diabetic GLP-1 drugs. Weight loss medications have an available weight loss PA program that manages appropriate use of those medicines – including the GLP-1 drugs approved for chronic weight management. The changes to the type 2 diabetes GLP-1 PA program are not connected to any weight loss drug coverage an employer may also have in place.

What’s next: BCBSIL Special Investigations Department is actively collaborating with Prime Therapeutics® to monitor and intervene on abnormal pharmacy dispensing and prescriber utilization and include provider education on the appropriate diagnosis required for GLP-1 medications that are indicated for diabetes.

BCBSIL continues to monitor market changes and medication utilization. Pharmacy clinical management strategies will be adjusted as needed to best support members while managing total cost of care for employer groups.

Blue Cross and Blue Shield of Illinois contracts with Prime Therapeutics to provide pharmacy benefit management and related other services. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics. MyPrime.com Leaving site icon is an online resource offered by Prime Therapeutics.

printer icon