Treating Type 2 Diabetes and the Truths about GLP-1 Drugs

Every day you are likely to see patients who have Type 2 Diabetes, a condition impacting approximately 1 in 10 or 33 million-plus Americans, according to the CDC. However, what is becoming just as common are questions from your patients around GLP-1 agonists (such as Ozempic, Trulicity, and Mounjaro); medications that were originally designed to treat Type 2 Diabetes and are now being prescribed to assist in weight loss.  

In the face of nationwide GLP-1 agonist shortages, it is important providers understand how these medications can be used, their side effects, and the impact the scarcity has on the treatment of life-threatening conditions.  

Approved by FDA in April 2005, GLP-1 agonists are a class of medication designed as a first- or second-line agent, after Metformin, used to treat Type 2 Diabetes. Working primarily in the gut, these drugs enhance insulin secretion and have become an integral tool in helping physicians manage diabetes.  And more recently, they are becoming more widely used to support and jumpstart weight loss - suppressing glucagon secretion, delaying gastric emptying, reducing appetite, and promoting production of beta cells.  

Whether used for the treatment of Type 2 Diabetes or weight loss, physicians should ask the following questions to know if this medication is right for their patients before prescribing.  

• For diabetes management: 
• How old is my patient? 
• Has my patient tried and failed or is not able to tolerate Metformin? 
• Can my patient handle injectable medications? 
• Would daily dosing or weekly dosing be more appropriate based on patient compliance? 
• If the medication is not effective enough, can we titrate the dose up before switching to new therapy? 
• For weight loss: 
• Has my patient tried lifestyle modifications, including exercise and healthy eating? 
• Are there any outside factors playing a role in weight gain? 
• Do any of the medications that my patient is taking have a side effect for weight gain? 

In addition, providers need to consider if the side effects, such as abdominal pain, hypoglycemia, pharyngitis, are manageable to the patient. 

While GLP-1 agonists secondary purpose is weight loss, it is this usage that is also impacting availability. To ensure your Type 2 Diabetes patients have the needed medications, refer to the below chart as reminder to prescribing guidelines.  

GLP-1 Agonists at a Glance 

*** - New product FDA approved on November 8^th, 2023 

More Information on Coverage Considerations 

AvMed Commercial and Medicare pharmacy coverage for GLP-1 drug class is for FDA-approved indications only related to treatment of type 2 diabetes. AvMed does not cover or approve prior authorization requests for off-label indications.  

Additionally, medications used for weight loss/management are excluded from coverage under Medicare federal regulations and AvMed’s health insurance plans. Requesting an authorization for drugs like Wegovy, Saxenda, Zepbound or other medications for weight loss/management will result in denial.  

• What should be considered and included when submitting a prior authorization? 
  • Provide clinical documentation/lab work with evidence of a type 2 diabetes diagnosis when submitting a request – evidence of diagnosis can be demonstrated by meeting any of the following criteria: 
    • A1C greater than 6.5%  
    • History of a 2-hour plasma glucose (PG) greater than or equal to 200 mg/dL during oral glucose tolerance test (OGTT) 
    • History of symptoms of hyperglycemia (e.g., polyuria, polydipsia, polyphagia) or hyperglycemic crisis and a random plasma glucose greater than or equal to 200 mg/dL 
    • History of a fasting plasma glucose (FPG) greater than or equal to 126 mg/dL with the patient having fasted for at least 8 hours prior to the fasting plasma glucose (FPG) test 
  • What will lead to a denied request? 
    • If a patient is not a type 2 diabetic or does not have the clinical documentation necessary to support the request 
    • Any request for a GLP-1 agonist for the use of an off-label indication (e.g., prediabetes, metabolic syndrome, polycystic ovarian syndrome (PCOS)) 
    • Any request for a GLP-1 agonist for the use of weight loss/management - Submitting a GLP-1 request for weight loss/management will result in a denial. Avoiding these submissions will help prevent unnecessary administrative burdens to providers, their staff, and to the insurance provider.

Listed below are the preferred GLP-1 drugs covered by AvMed for type 2 diabetes with clinical documentation for a diabetes diagnosis (plan dependent): 

• Mounjaro  
• Ozempic  
• Rybelsus  
• Trulicity  
• Victoza