Ozempic® is an injectable diabetic medicine used to improve glycemic control in adults for type 2 diabetes management. Please see our May 2021 Newsline New Package Size Available for Ozempic® for reference on how to bill for Ozempic®. On June 4, 2021, the FDA approved a new drug treatment for chronic weight management called Wegovy™ which has the exact same ingredient – semaglutide.
Similarly, Victoza® is also used to improve glycemic control in patients 10 years and older for type 2 diabetes and is composed of an ingredient called liraglutide. Saxenda® also contains liraglutide but is used for chronic weight management. Pharmacies need to be aware that there is an audit risk if the prescriber is ordering for off-label use.
|GLP-1 Receptor Agonist||Analog Name||FDA Indication||Goal Dose|
|Ozempic®||semaglutide||Type 2 diabetes management||0.5 mg or 1 mg weekly|
|Wegovy™||semaglutide||Chronic weight management||2.4 mg weekly|
|Victoza®||liraglutide||Type 2 diabetes management||1.2 mg or 1.8 mg daily|
|Saxenda®||liraglutide||Chronic weight management||3 mg daily|
- Prescribers may try to help patients get around plan exclusions for weight loss medications by prescribing Ozempic® or Victoza® at higher doses
- FDA approved medications being used off-label like this would likely not be covered under federal programs and are subject to audit recoupment
- Claims paid at point-of-sale do not guarantee payment
- If a prescription is written for the Analog name, pharmacies need to confirm the diagnosis to bill the correct medication
- These products come in multiple strengths and package sizes which would also need to be confirmed
- Medicare Part D and Medicaid may restrict coverage of medications if the prescribed use is not for a medically accepted indication
- Update: Medicare Part D Mandatory E-Prescribing Requirements for Controlled Substances – Final Rule - January 11, 2023
- DMEPOS Mini-Series #8 – The Six Medicare Auditing Entities and Their Purpose - December 20, 2022
- Be on the Lookout for OptumRx Unannounced Onsite Audits - December 18, 2022