Billing Ozempic® 0.25 mg Weekly as Maintenance – What PBMs Say

calling the geriatrician to explain that 0.25 mg is subtherapeutic for the frail 91-year-old patient isn’t always time well spent, it is worth confirming that the dose prescribed was truly the maintenance dose intended (and documenting the conversation on the hardcopy accordingly).

With the duplicity of GLP-1 medications being marketed separately for Type II Diabetes Mellitus or Weight-loss, there is a heightened sense of off-label use when Ozempic^® [instead of Wegovy^®] is prescribed for weight loss. Likewise, Ozempic 0.25 mg could be considered “off-label use”, although PBMs seem reluctant to do anything [at least for now] to disrupt the gravy train that is GLP-1 rebates.

So, beyond validating the ongoing Ozempic 0.25 mg dosing, how should pharmacies bill the claim? There are only 6 pen needles in the box, so an argument could be made that the days’ supply should be 42. However, this would be wasting two weeks’ worth of medication, and pen needles can be dispensed and sold separately (as is the case with insulin pens).

CVS/Caremark is the only PBM with written guidance available on their Audit Tips: Injectable GLP-1 Receptor Agonist Medications resource. Caremark states that a box of Ozempic^® 2 mg/3 mL giving 0.25 mg once weekly should be billed as a 56-day supply. With this billing guidance (which has not to our knowledge been spelled out before), it is likely to continue being an audit target. Caremark does state that if the plan limits the days’ supply to 34, to call the help desk to request a “Plan limitation exceeded” override and to document that information on the hard copy.

As for other PBMs, there has been no formal guidance as to the correct billing of the low-dose Ozempic^®. PAAS has seen Express Scripts also indicate (per audit results) that low-dose Ozempic^® at 0.25 mg once weekly ongoing as a 56-day supply. OptumRx, on the other hand, believes these directions constitute a 42 days’ supply (likely due to the limited pen needles available). PAAS considers the conservative approach to be always billing for a 56-day supply and dispensing/selling additional pen needles, as needed.

The recoupment risk for pharmacies billing a 42 days’ supply for low-dose Ozempic^® is the initial dispensing will be flagged for incorrect days’ supply and subsequent refills may be deemed as refill too soon (facing full recoupment). Any refills that are dispensed prior to the PBM’s utilization threshold [based on the actual days’ supply] is easily identified by the PBM and low hanging fruit for auditors (before they even asked for prescription documentation). If the PBM wanted a 56 days’ supply and the utilization threshold is 75%, pharmacies refilling prior to 42 days could face recoupment.

PAAS Tips:

• PAAS recommends billing Ozempic® 0.25 mg weekly as a 56-day supply to maintain consistency and avoid potential recoupment
  • Be careful of early refills if you must submit an altered day supply due to plan limitations
    • Utilization thresholds vary by plan and PBM – be judicious when allowing refills to process
  • See PAAS tool Exceeding Day’s Supply Plan Limitations for Unbreakable Packages to educate your team and develop a systematic process for handling these types of prescriptions
• Advise patient to NOT re-use pen needles
• Optum Rx Provider Manual states that the pharmacy should contact the help desk for an override if the days’ supply billed exceeds the plan limit, then document on the prescription hard copy
• Ozempic^® 0.25 mg weekly is not considered to be a therapeutic dose and could be considered off-label use
  • Medicare Part D and other federally funded plans will not pay for drugs for off-label use. Commercial plans can also deny payment, depending on the agreement/provider manual
• Ensure any diagnosis code present on the prescription is approved for use of Ozempic®
• If utilizing a coupon card, ensure it is being used in accordance with the terms and conditions listed