PBM Audits on Ozempic®: 5 Common Discrepancies Revealed

1. Quantity
   1. NCPDP billing unit is mL, therefore the prescriber should be ordering the quantity as 3 mL, 6 mL, or 9 mL
   2. If ordered as a quantity of 1 kit or 1 unspecified, PBMs will mark the claim discrepant
2. Unit of Measure (UOM)
   1. If the UOM is missing, “unspecified,” or written for a UOM other than mL, it will lead to a discrepancy upon audit
3. Directions
   1. Prescribers should include how many mg are being used per week in the directions.
      1. Prescribers may erroneously write directions in mL vs mg
      2. Pharmacies may input directions incorrectly as mL vs mg
4. Prescribing
   1. Be sure the prescription is written for a strength that matches the dose being prescribed
      1. Example – prescription written for dosage that does not align with the product ordered
         1. Prescriber wrote for Ozempic^® 2 mg pen, but the directions indicate to use 1 mg weekly
   2. Prescribers often write for the 0.25 mg once weekly dosing with no titration. The recommended dosage of the manufacturer product label (section 2.2) states:
      • • Initiate Ozempic^® with a dosage of 0.25 mg injected subcutaneously once weekly for 4 weeks. The 0.25 mg dosage is intended for treatment initiation and is not effective for glycemic control.
        • After 4 weeks on the 0.25 mg dosage, increase the dosage to 0.5 mg once weekly.
        • If additional glycemic control is needed after at least 4 weeks on the 0.5 mg dosage, the dosage may be increased to 1 mg once weekly.
        • If additional glycemic control is needed after at least 4 weeks on the 1 mg dosage, the dosage may be increased to 2 mg once weekly. The maximum recommended dosage is 2 mg once weekly.
5. Off-label use
   1. Ozempic^® is FDA approved for Type II diabetes (T2D). If prescribing for anything other than T2D, it could be considered off-label and flagged for recoupment by the PBM, especially for Medicare and Medicaid plans as they do not pay for off-label use and Medicare Part D, by law, does not cover weight loss drugs.

PAAS Tips:

• Review the following Newsline articles for additional information:
  • August 2023, Considerations With Ozempic 0.25 mg Weekly
  • May 2023, Ozempic Package Size Change
  • May 2023, Best Practices for Dispensing GLP-1 Medications and Reducing Recoupment Risk
  • September 2021, Electronic Prescriptions – Quantity Unit of Measure