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SPECIALTY CARE
We are pleased to offer the latest version of our medications and CGM coverage guide, refreshed with the latest 2023 Q1 formularies and DME policies available, as of January 2023.
New to this all-in-one guide is an appendix page, linking to all plans' 2023 formularies, step therapy and prior authorization policies, and DME diabetes supplies policies, when available.
Download the GLP-1 Receptor Agonist Shortages: A Guide to Supporting Patients
Guide to glp1 shortages
Major trends in coverage in 2023
A Mounjaro Wave
In Q1 2023, we saw multiple commercial plans adopt coverage for Mounjaro (tirzepatide), a first-in-class combination GLP-1 RA and GIP. Here's a summary of changes based on 2023 formularies.
Priority Health Optimized: Now covers Mounjaro as a Preferred Tier 2 (Brand) drug, with prior authorization. Please review the plan’s PA criteria, as it is more stringent than Priority Health Traditional commercial plan.
HAP commercial: Now covers Mounjaro.
United commercial: Now covered with Prior Authorization/Step Therapy, defined as a trial of or contraindication to metformin.
Blue Cross Blue Shield of Michigan commercial: Mounjaro is Non-Preferred with Prior Authorization, defined in their formulary as "For the treatment of Type 2 Diabetes or trial of one generic or preferred medication for the treatment of Type 2 Diabetes.”
Mounjaro was approved by the U.S. Food and Drug Administration in Summer 2022 and was the subject of discussion for one of our Fall 2022 regional meeting guest speakers and MCT2D endocrinology member, Dr. Jamal Hammoud, MD, FACE, Clinical Professor of Medicine, Michigan State University.
Adlyxin
Farxiga and Invokana
United Commercial: Farxiga (dapagliflozin) and Invokana (canagliflozin) changed from “Non Preferred with ST” to “May be excluded from coverage or subject to PA in CT, NJ and NY.”
Phentermine
Aetna commercial: No longer covered
ExpressScripts: No longer covered
Qsymia (phentermine-topiramate)
HAP commercial: Changed from "Not Covered" to "Not-Preferred, higher cost, with prior authorization"
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Support for The Michigan Collaborative for Type 2 Diabetes (MCT2D) is provided by Blue Cross Blue Shield of Michigan as part of the BCBSM Value Partnerships program.
Although Blue Cross Blue Shield of Michigan and MCT2D work collaboratively, the opinions, beliefs and viewpoints expressed by the author do not necessarily reflect the opinions, beliefs and viewpoints of BCBSM or any of its employees.