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PBM Benefit Insights

Ozempic for weight loss: Is your self-funded plan impacted?


It's hard to miss the growing popularity of Ozempic, prescribed off-label for weight loss. Paying extra attention to the PBM contract is important if you are a self-funded Plan Sponsor or Benefit Consultant.


A newer class of diabetes therapy drugs, like Ozempic, averaging $1,000 per month, is becoming an unprecedented challenge to PBMs and Plan Sponsors. Does your PBM plan have the appropriate utilization management in place?


Ozempic has strong brand awareness, with a well-known commercial jingle, and is a very effective medication for type 2 diabetes. However, most PBMs require step therapy, and most patients with Type 2 are not immediately prescribed Ozempic. In many cases, they start with Metformin, considered the gold standard.


If you are a Benefit Advisor or Plan Sponsor of a self-funded plan, you might wonder how your current PBM will mitigate this new health trend. Your organization's demographics play a large role in aligning your cost-containment strategies and pharmacy benefit plan design. Is your current PBM focused on your organization's needs? Are they prepared to provide oversight and clinical guidance?


Here are some other important questions to ask about your current PBM contract:

  • Does the plan have or allow for coverage policies and requirements such as Prior Authorizations, Step Therapy, and Quantity Limits?

  • Does the PBM provide Monitoring and Reporting to track utilization and cost trends?

  • Is the PBM contract flexible to allow Cost Containment Strategies so the sponsor can better manage the plan's overall spending?

In some cases, it may be necessary to implement a standard exclusion for all weight loss products. Mounjaro, Eli Lily's weight loss drug, is awaiting FDA approval and is set to be a blockbuster brand ready to compete with Ozempic's market share.


Contact an APC Pharmacy Benefit Consultant to discuss how we can help identify the highest-cost drugs and evaluate your self-funded health plan's trends and patterns in utilization. APC can evaluate the effectiveness of your plan design and benchmark it against industry standards to provide valuable insights to help with cost-saving decisions.




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