It seems that many endocrinologists, internists, and family practice physicians, in general, have no idea how to write an effective prior authorization for GLP-1s for their Type 1 diabetic patients! Many seem to even argue that GLP-1s are only for T2Ds.
During the ADA Scientific Sessions Conference this week in Chicago, I asked 7 of the brightest, world-renowned, and most progressive U.S. endocrinologists: Do you have a standard format letter that you use to complete Prior Authorizations or a one-sheet that validates the use of GLP-1s for Type 1 diabetes (T1D).
Here are their answers, which may help you if you want to try using the latest diabetes therapies and are encountering prior authorization roadblocks. Please feel free to share this with your healthcare providers.
“Anyone injecting insulin into fat has iatrogenic insulin resistance (see multiple excellent talks from Jeremy and Steve – see links to share below). Insulin resistance is sufficient to provide a dual diagnosis of type 1 and type 2 diabetes. Plenty of people with type 1 also have obesity (although coverage for Wegovy and Zepbound varies by payor), so between all those factors, we can often get it covered without a prior auth – although someone might have to “fail” metformin. Of note, we do still have problems with Tirzepatide in <18yo, but that’s just because of the current labeling. Semaglutide is not a problem.”
“I agree. We have only had one insurer refuse to allow us to “double code”. Mounjaro can be harder to get. Sometimes people have had to try and “fail” Rybelsus, Trulicity, metformin, and Ozempic first…which happens all the time. And as long as it is documented, nearly everything is possible.”
“Like most meds, things are tougher in the Pacific Northwest. We have tried to code every way possible, and it rarely works, and there is no coverage that I have seen for obesity. While there is clearly a spectrum between type 1 and type 2 diabetes (and “double diabetes”), that doesn’t work with our payors. At least for now, patients can go to Canada where there are pharmacists in the border pharmacies. You pay them $50, and you can then pay cash for the drug, generally much cheaper than mail order from Canada. The problem with that is you only get 3 months at a time. That means four trips to Canada each year, which few can afford. Because NovoNordisk failed to pay some fee, we will have generic Ozempic in Canada next year!”
“I use this smart phrase. Sometimes it works. If the BMI meets the criteria for the therapy, prescribe Wegovy or Zepbound and only associate it with an Obesity diagnosis, excluding diabetes. If it still doesn’t work, we try different appeal letters, most of the time something eventually works :
The patient will benefit from GLP-1 due to insulin resistance, high insulin dose requirements, reduction of cardiovascular risk factors, and the presence of features of type 2 Diabetes. Note: Patients with Type 1 Diabetes are not precluded from developing Type 2 Diabetes and are, in fact, more likely to develop metabolic features such as insulin resistance than the general population. This patient, as documented above, has BOTH type 1 AND type 2 diabetes.”
Some resources if your HCP needs “proof”
TCOYD: What Is Insulin Resistance and How Do You Know If You Have It?
Breakthrough T1D: Could drugs like Ozempic also benefit people with type 1 diabetes?
