A message from Atheer Kaddis, vice president, Pharmacy Services
Tackling the affordability challenge for diabetes and weight loss drugs

We have an obesity problem and a diabetes problem in the U.S., and the two problems are often related. More than 70 million adults in the U.S. are obese or overweight. And obesity can lead to Type 2 diabetes, among other conditions. About 37 million people have Type 2 diabetes, according to the Centers for Disease Control and Prevention, and another 100 million are on their way to developing it. These are disturbing statistics.

Since diabetes affects so many individuals, any change in treatment has far-reaching effects. While the U.S. Food and Drug Administration approved a class of drugs called GLP-1, or glucagon-like peptide 1 agonists, several years ago to treat Type 2 diabetes, additional versions of the GLP-1 agonists were recently approved by the FDA specifically for weight loss. Updated treatment guidelines by the American Diabetes Association, an aggressive campaign by pharmaceutical manufacturers and information shared on social media increased demand for them among people seeking to lose weight. This resulted in a troubling shortage that affected many patients with Type 2 diabetes.

To encourage appropriate use of these drugs for commercial members, Blue Cross Blue Shield of Michigan and Blue Care Network enacted the following requirements earlier this year:

• Patients must be diagnosed with Type 2 diabetes to receive drugs approved for Type 2 diabetes. These drugs will no longer be approved for weight loss alone. We began requiring prior authorization for GLP-1 agonists for diabetes for new users on Feb. 1, 2023, although the drugs didn’t require prior authorization for current users until Aug. 15, 2023.

• For drugs approved by the FDA specifically for weight loss, we require prior authorization and have other coverage requirements. Providers must attest that their patient has provided them with proof of participation in appropriate lifestyle modifications (diet, exercise or participation in a formal lifestyle program, such as Noom or Weight Watchers) for both initial prior authorization approval and for renewing prior authorization.
  
  In addition, the initial prior authorization period will be shortened from 12 months to four months to ensure appropriate provider follow-up. These changes were effective Sept. 1, 2023. For more details, see this August Record article.  

Cellular and gene therapies
In other drug developments, new specialty treatment options have been entering the market for rare conditions, including genetic childhood blindness, hemophilia and certain cancers. While they’re often effective for some patients, they’re also costly. For instance, the most expensive FDA-approved gene therapy currently costs as much as $4.2 million for a one-time treatment.

Blue Cross is closely monitoring the drug pipeline to help ensure our members — your patients — have access to safe and effective treatment for rare or life-altering conditions, while striving to minimize the financial risk placed on our organization, our customers and our members due to these expensive treatments. As we develop new evidence-based medical policies and guidelines, as well as products to help our customers cover these expensive therapies, we’ll keep you informed.

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.