February 2023 AI Alert

Gains and Losses with Weight Loss Prescription Drugs

Three weight-loss drugs are approved by the FDA (Food and Drug Administration) for persons with type 2 diabetes and obesity, and the names of the generic drug are tirzepatide, liraglutide, and semaglutide. Collectively, the brand names of these weight-loss drugs include Mounjaro, Ozempic, Wegovy, Rybelsus, Saxenda, and Victoza. Most of these weight-loss drugs are approved for adults; however, Wegovy, Saxenda, and Victoza are approved for children if they meet certain weight and/or BMI (Body Mass Index) levels.

Three additional weight-loss drugs approved by the FDA that are not specific to type-2 diabetes patients who are obese or overweight with weight-related medical conditions and the generic drug names are orlistat [prescription and OTC], naltrexone and bupropion [combination], and phentermine and topiramate [combination]. Collectively, the brand names of these weight-loss drugs include Qsymia, Alli, Xenical, and Contrave. Contrave is approved for adults and Qsymia, Alli, and Xenical are approved for children if they meet certain weight and/or BMI levels.

Most importantly, concurrent use of more than one weight-loss drug is a major contra-indication and poses a serious health risk to the patient.

Over the past year, Ozempic, Mounjaro, and Wegovy have been featured in the news and in social media as weight-loss miracle drugs. Patients with a medical necessity for these drugs to manage their weight and reduce their risks of adverse cardiac events are now having difficulty finding the medication they need due to the volume of prescriptions for off-label use.

Allowing off-label use of weight-loss drugs intended for type 2 diabetes patients will impact the supply chain for the patient population with a medical need, increase your overall health plan spend, and create long-term, health care costs in patients that develop unforeseen conditions associated with off-label use. Given the potential for abuse, we recommend health plans review any policies related to these medications including preauthorization, prerequisite conditions, treatment periods, and off-label utilization in the non-type 2 diabetic population

Collusion

In the world of ‘Prescription Fraud,’ health plans must first determine the ‘Subject’ of the investigation or review. This could be the member, the pharmacy, or the authorizing physician. There are instances where a prescription fraud investigation may involve (2) or more subjects, such as the doctor and the filling pharmacy. This example is called collusion and is quite common in the pharmacy space.

Determining the top authorizing physician is essential if a user identifies a pharmacy billing many weight loss prescription drug claims. This analysis could help to tell if the pharmacy and doctor have a business relationship. If the data reveals that a doctor is sending a high percentage of prescriptions to a particular pharmacy, further reviewing those claims is a recommended step in the investigation.

Furthermore, analyzing the specialty of the prescribers would also be beneficial. Obesity or weight management is often treated by gastroenterologists, clinicians within the bariatric specialty, gynecologists, or some family doctors. If a user identifies claims for weight-management drugs that fall outside of said specialties, it is recommended to review those claims for ‘out of specialty prescribing.’ This analysis could be done by viewing the prescriber’s specialty histogram within the Codoxo platform.

Steering

There has been a rise in prescription fraud cases concerned with ‘steering.’ An example of steering is a member using their local retail/chain pharmacy for everyday maintenance drugs but is billed a high-cost drug by a pharmacy they never use. When interviewing these members, they typically say that the doctor told them or ‘steered’ them to use the pharmacy.

Wegovy, Ozempic, or Mounjaro are not considered specialty drugs. These drugs do not treat chronic critical illnesses such as cancers or multiple sclerosis (MS), they do not require special handling, nor are they considered limited distribution drugs or “LDD.” As such, most pharmacies can order these drugs through their wholesaler and dispense them to the patient. That said, if members use their primary pharmacy for every day or maintenance drugs, they can also obtain their drugs for weight management from the same pharmacy.

Using Codoxo’s Fraud Scope to assist health plans with assessing weight loss drug utilization

Codoxo created three Fraud Scope queries to assist their health plan partners with collecting weight loss drug prescription intelligence by Brand Name. Informatively, the Fraud Queries applied all prescribing or filling specialties, which can be edited after the results are published.

• • Prescribing Aggregates of Weight Loss Drugs
  • Filling Pharmacy Aggregates of Weight Loss Drugs
  • Prescription Claims for Weight Loss Drugs, Written Jan 01, 2021+

Navigate to Query and select Library from the drop-down menu. Click on the Fraud Scope query you want to review. If the query name does not appear near to the top of the query table, click the drop-down for the Description column, enter the term “Weight Loss”, click Apply, and then click your preferred Fraud Scope query.

Analyzing results from the ‘Prescribing Aggregates of Weight Loss Drugs’ query

After the results are published, click Show Chart, and build the following charts as a starting point for analyzing prescribers. Additional Show Chart options are available based on the analysis needs for the user and health plan.

Editing Prescribing Specialties

Fraud Scope users can update the query criteria to eliminate expected prescribing peer groups, such as Endocrinology or Pediatric Endocrinology, using the following steps:

• • Click Edit icon in the top left corner of the Query window
  • Clicking Prescribing Specialties in the ‘Select at Least 1 Specialty’ menu
  • Clicking Select All and notice All Selected appears in the ‘Select at Least 1 Specialty’ menu
  • Type Endo in the search bar and deselect the peer groups for elimination from the results
  • Repeat these steps to eliminate other prescribing specialties for summary analysis
  • Click Search to update the query results
  • Click Plot Chart to update an existing chart model for analysis

***Editing the Prescribing Specialties does not overwrite the Query, Library Fraud Scope criteria***

Further analysis within the Prescribing Aggregates table is available when users apply Primary Sort, descending on the Utilization Percent Difference column, which identifies the prescribers with the highest utilization compared to their prescribing peers. Since Alli and Xenical are available OTC, a prescriber with a high utilization percent difference for these drugs may be of interest, depending on the cost comparisons.

Analyzing results from the ‘Filling Pharmacy Aggregates of Weight Loss Drugs’ query

After the results are published, click Show Chart, and build the following charts as a starting point for analyzing filling pharmacies. Additional Show Chart options are available based on the analysis needs for the user or health plan.

Further analysis within the Filling Pharmacy Aggregates table is available when users apply Primary Sort, descending on the Utilization Percent Difference column, which identifies the filling pharmacies with the highest utilization compared to their filling peers. Since Alli and Xenical are available OTC, a filling pharmacy with a high utilization percent difference for these drugs may be of interest, depending on the cost comparisons.

Analyzing results from the ‘Prescription Claims for Weight Loss Drugs, Written Jan 01, 2021+’ query

After the results are published, click Show Chart, and build the following charts as a starting point for analyzing prescribers and patients of interest. Additional Show Chart options are available based on the analysis needs for the health plan. Fraud Scope users can update the query criteria to eliminate expected prescribing peer groups, such as Endocrinology or Pediatric Endocrinology – please refer to the Editing Prescribing Specialties section outlined above.

Reviewing patients with weight loss prescriptions

When a Patient ID displays prescriptions for more than one weight loss drug, especially those with mixed prerequisite conditions, the user should click on the Patient ID to navigate to the Patient, Lines page. Click Show Chart, choose Diagnosis Code as Variable 1 and click Plot Chart. When that chart is published, Fraud Scope users can reference the following tables for the expected diagnosis codes in a patient history based on their prescription history.

Patients with prescriptions for Mounjaro, Ozempic, Wegovy, Rybelsus, Saxenda, or Victoza should display a type-2 diabetes diagnosis code and at least one obesity diagnosis code in their medical history. If type-2 diabetes codes are absent, identify the prescribing provider[s] in the Prescriptions sub-menu for additional review. Consider assessing prescriptions based on Patient Age for Wegovy, Saxenda, and Victoza.

Table 1: Prerequisite diagnoses for Mounjaro, Ozempic, Wegovy, Rybelsus, Saxenda, or Victoza

Patients with prescriptions for Qsymia, Alli, Xenical, or Contrave should display at least obesity and/or BMI diagnosis code from the range in Table 2 in their medical history. If those codes are absent, identify the prescribing provider[s] in the Prescriptions sub-menu for additional review. Consider assessing prescriptions based on Patient Age for Qsymia, Alli, and Xenical.

Table 2: Prerequisite diagnoses for Qsymia, Alli, Xenical, or Contrave

If you are interested in learning more about Codoxo’s forensic AI platform or would like to speak to Codoxo team member, contact us via info@codoxo.com.

References:

1. NBC News Report on Ozempic Shortages
   https://www.nbcnews.com/health/health-news/people-diabetes-struggle-find-ozempic-soars-popularity-weight-loss-aid-rcna64916\

2. National Institute of Diabetes and Digestive and Kidney Diseases
   https://www.niddk.nih.gov/health-information/weight-management/prescription-medications-treat-overweight-obesity

3. National Library of Medicine [Information regarding generic names of weight loss drugs]

Tirzepatide https://medlineplus.gov/druginfo/meds/a622044.html

Semaglutide https://medlineplus.gov/druginfo/meds/a618008.html

Liraglutide https://medlineplus.gov/druginfo/meds/a611003.html

Naltrexone and Bupropion https://medlineplus.gov/druginfo/meds/a619020.html

Phentermine and Topiramate https://medlineplus.gov/druginfo/meds/a612037.html

Orlistat https://medlineplus.gov/druginfo/meds/a601244.html