How Prime Therapeutics Tugged on the Reins of the Galloping GLP-1 Spend | AMCP Nexus 2023

The glucagon-like peptide (GLP-1) agonists, such as Ozempic (semaglutide), Mounjaro (tirzepatide) and Trulicity (dulaglutide), and the dipeptidyl peptidase-4 (DPP4) inhibitors, such as Januvia (sitagliptin) and Tradjenta (linagliptin), are prescribed to treat diabetes. The GLP-1s have also made front-page news as weight-loss drugs, with many of the prescriptions being written off-label. As prescriptions have surged and expenditures soared on the GLP-1s, payers have taken steps to rein in the prescribing.

Prime Therapeutics, a pharmacy benefit manager headquartered in the suburban Twin Cities in Minnesota, presented data at the Academy of Managed Care Pharmacy (AMCP) Nexus 2023 meeting this week in Orlando suggesting that reducing instances of duplicative prescribing of GLP-1s and DPP4 inhibitors might be a good, if modest, first step for many payers to take.

Although they have different mechanism of action, the GLP-1s and the DPP4 inhibitors both work through the incretin system; they are sometimes grouped together under the heading of incretin drugs. There appears to be no diabetes-related benefit to prescribing them together, and there might be some increased risk of side effects.

Prime’s data, presented in a poster that won AMCP's platinum ranking, showed that an automated claims review process could identify duplicative therapy: either a GLP-1 and DPP4 inhibitor together, two GLP-1s or two DPP4 inhibitor prescriptions. After that, follow up by a pharmacist with prescribers resulted in 467 patients switching from duplicative therapy to either a single GLP-1 or DPP4 inhibitor. That switch yielded an average of just over $7,500 in savings per patient, or $3.5 million in total; the poster said another $3.5 million in savings is “in progress." Lead researcher Nicholas Friedlander, Pharm.D., and his Prime Therapeutics computed the per-member, per-month (PMPM) savings to be $0.024.

Friedlander and his colleagues wrote in their poster that the incretin class now accounts for more than $20 PMPM of all drug expenditures and increased by 50% from mid-2022 to mid-2023.

“Managed care pharmacy programs to eliminate duplicative incretin therapy for a member is one means to ensure appropriate therapy; reducing member share cost, insurer costs and member drug side effect risk,” they wrote in their conclusion.

Prime has dubbed its review and outreach program HighTouchRx. Friedlander and his colleagues sifted through claims from February 2023 through July 2023 and identified 217,737 commercially insured members of Prime with either a GLP-1 or DPP4 inhibitor claim. Of those, 4.5%, or 9,833, had claims indicating duplicative therapy. Most (75.5%) patients had a GLP-1 and a DPP4 inhibitor prescription but a large minority (23.8%) had prescriptions for GLP-1s. There was also a small group (0.7%) that had claims for two DPP4 inhibitors prescriptions.

A large fraction (more than 75%) of the duplicative incretin cases were not reviewed by a pharmacist. And of those that were reviewed, more than half (53.9%) presented no real opportunity for the pharmacist to reach out to the prescriber and change the prescription because the person had stopped taking the drugs (making any kind of outreach to stop duplicative therapy moot) or the person was no longer covered by one of the Blues plans that Prime works with.

Approximately 15% of the outreach efforts by the pharmacist did, though, result in the patient switching from duplicative therapy to a single drug. Approximately 8% were “unsuccessful” either because the prescriber never responded or refused to make the change or for “other reasons stated.”