PBM Audits on Ozempic®: 5 Common Discrepancies Revealed
Popularity for GLP-1 medications, like Ozempic®, continues to grow and, consequently, PAAS National® encounters these drugs on PBM audits frequently. This article outlines five common discrepancies observed in audit findings for Ozempic®.
- Quantity
- NCPDP billing unit is mL, therefore the prescriber should be ordering the quantity as 3 mL, 6 mL, or 9 mL
- If ordered as a quantity of 1 kit or 1 unspecified, PBMs will mark the claim discrepant
- Unit of Measure (UOM)
- If the UOM is missing, “unspecified,” or written for a UOM other than mL, it will lead to a discrepancy upon audit
- Directions
- Prescribers should include how many mg are being used per week in the directions.
- Prescribers may erroneously write directions in mL vs mg
- Pharmacies may input directions incorrectly as mL vs mg
- Prescribers should include how many mg are being used per week in the directions.
- Prescribing
- Be sure the prescription is written for a strength that matches the dose being prescribed
- Example – prescription written for dosage that does not align with the product ordered
- Prescriber wrote for Ozempic® 2 mg pen, but the directions indicate to use 1 mg weekly
- Example – prescription written for dosage that does not align with the product ordered
- Prescribers often write for the 0.25 mg once weekly dosing with no titration. The recommended dosage of the manufacturer product label (section 2.2) states:
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- Initiate Ozempic® with a dosage of 0.25 mg injected subcutaneously once weekly for 4 weeks. The 0.25 mg dosage is intended for treatment initiation and is not effective for glycemic control.
- After 4 weeks on the 0.25 mg dosage, increase the dosage to 0.5 mg once weekly.
- If additional glycemic control is needed after at least 4 weeks on the 0.5 mg dosage, the dosage may be increased to 1 mg once weekly.
- If additional glycemic control is needed after at least 4 weeks on the 1 mg dosage, the dosage may be increased to 2 mg once weekly. The maximum recommended dosage is 2 mg once weekly.
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- Be sure the prescription is written for a strength that matches the dose being prescribed
- Off-label use
- Ozempic® is FDA approved for Type II diabetes (T2D). If prescribing for anything other than T2D, it could be considered off-label and flagged for recoupment by the PBM, especially for Medicare and Medicaid plans as they do not pay for off-label use and Medicare Part D, by law, does not cover weight loss drugs.
PAAS Tips:
- Review the following Newsline articles for additional information:
- August 2023, Considerations With Ozempic 0.25 mg Weekly
- May 2023, Ozempic Package Size Change
- May 2023, Best Practices for Dispensing GLP-1 Medications and Reducing Recoupment Risk
- September 2021, Electronic Prescriptions – Quantity Unit of Measure
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