As healthcare continues to evolve, new medications and treatments are introduced to the market. Among the latest entrants are Ozempic and WeGovy, two drugs developed by Novo Nordisk, both of which contain the same active ingredient: semaglutide. While these drugs are gaining traction, especially due to their potential benefits, they also present unique challenges for health plans and pharmacy benefit managers (PBMs). Let's delve into why these medications have become a challenge to authorize and how Banjo Health might be the answer to their problems.
The Dual-Purpose Nature of the Drugs
Ozempic, originally authorized as a type 2 diabetes medication, has also been recognized for its weight loss benefits. Similarly, WeGovy, specifically developed for weight management in adults, can also be used off-label for diabetes. This duality of purpose presents a challenge for health plans and PBMs when it comes to categorizing, approving, and pricing the drugs.
High Cost of the Medications
Both Ozempic and WeGovy are priced at a premium, especially in comparison to other drugs in the GLP-1 agonist class or weight loss medications. The high price tags can lead to increased costs for payers, who are always attempting to balance premium medications with sustainable economics.
Popularity Amidst the Obesity Epidemic
With the growing obesity epidemic in many western countries, the demand for effective weight management solutions is also rising. As more patients and doctors turn to Ozempic and WeGovy as potential solutions, the volume of authorization requests may become overwhelming for health plans and PBMs.
Concerns Over Off-Label Usage
While physicians may legally prescribe medications off-label, PBMs and health plans often have guidelines that are narrower to ensure the most appropriate and cost-effective use of medications. Given the potential for off-label use of these drugs, especially given their dual functionalities, this can become a contentious issue for authorizations.
Long-Term Effects and Safety
Any new medication, despite passing through rigorous trials, will have its long-term effects monitored once it's widely used in the general population. As PBMs and health plans look to manage their risks, they may be hesitant to widely authorize drugs until there is substantial real-world data backing their long-term safety.
Complexity in Benefit Design
Given the dual-use nature of these drugs and their high costs, health plans and PBMs may face challenges in determining which benefit – pharmacy or medical – should cover the medication. This could further complicate approval processes and formulary placements.
Conclusion
Enter Banjo Health
Banjo Health’s Composer, an automated clinical criteria decision mapping tool, allows clinicians to quickly implement and maintain even the most difficult of clinical criteria and cut the time needed to enact these policies by more than 70% even if there are multiple use cases for a single pharmaceutical.
With high numbers of members seeking out these Semaglutide therapies for weight loss, payers are starting to see a much higher volume in requests. With BanjoPA requests are digested automatically with a recommended response provided instantly to the clinician, drastically reducing the time needed to respond to each request. Expanding PA capacity without expanding team resources.
Ozempic and WeGovy may bring promise to many patients struggling with type 2 diabetes and weight management, but their rising popularity poses unique challenges for health plans and PBMs. As these entities grapple with the issues of categorization, cost, demand, off-label use, and long-term safety, it will be essential for them to find a balance that ensures patient access while also maintaining safe cost-effective care. While some of the factors listed above are out of the payers' control, Banjo Health can help them take back control of most of them and take the tedious workload of navigating complex therapies off the shoulders of health plans and PBMs.
