As of April 1, 2024, there is a new optional pharmacy benefit program available for Administrative Services Only groups with Prime Therapeutics called GLP-1 New to Therapy. This new program aims to reduce the drug waste and cost of care associated with beginning GLP-1 drug therapy. It can also help members utilize the medication as intended, based on FDA labeling, until they find their maintenance dosage. GLP-1 drugs that are indicated for Type 2 Diabetes and indicated for Weight Loss/Weight Management may be included in the program.
How it works: GLP-1 New to Therapy limits an initial fill(s) to 30 days when members are new to GLP-1 drug therapy. After the initial fill(s), members may be eligible for up to a 90-day supply, per their pharmacy benefits.
- A 30-day supply limit may continue to apply after the first fill if the member moves to a new dosing strength or changes to a different GLP-1 medication.
- Members may be impacted if they are new to GLP-1 therapy or have no claims history within the past 120 days.
- Members currently taking a GLP-1 drug on a maintenance dosage are not impacted.
- Drug products that can be included are: Adlyxin, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Saxenda, Trulicity, Victoza, Wegovy, and Zepbound. This list is subject to change.
The program categories and medications included, as well as any applicable prior authorization programs for GLP-1 and Weight Loss, would be based on the member’s pharmacy benefits. Please call the number on the member’s ID card to verify coverage, or for further assistance or clarification on your patient’s benefits.
The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are to exercise their own medical judgment. Pharmacy benefits and limits are subject to the terms set forth in the member’s certificate of coverage which may vary from the limits set forth above. The listing of any drug or classification of drugs is not a guarantee of benefits. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.
Prime Therapeutics LLC is a pharmacy benefit management company. BCBSNM contracts with Prime to provide pharmacy benefit management and related other services. BCBSNM, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. MyPrime.com is an online resource offered by Prime Therapeutics.