Insurance Coverage:
- The biggest factor is that the GLP1RA is prescribed on label.
- The following will require that patients have Type 2 diabetes:
- Mounjaro (tirzepatide), Ozempic (semaglutide), Rybelsus (oral semaglutide), and Trulicity (dulaglutide)
- The following have been approved for weight loss, but will require that the insurance provider covers weight loss. The patient must have a BMI of 30 or greater, or 27 or greater and at least one weight associated comorbidity (such as HTN, CVD, sleep apnea, or dyslipidemia):
- Zepbound (tirzepatide), Wegovy (semaglutide), Saxenda (liraglutide)
- There are coupons available through the pharmaceutical companies’ websites. Patients can print these off and bring them to the pharmacy.
- There is a cost estimator in Epic as you enter the medication in, located in the bottom right corner. Below are images from Epic showing this:
- After placing the order for the medication look down in the right-hand corner. Selected the “Estimate” option as circled in red.
2. After you select estimate the following box will pop in the middle of your page. If you select the down arrows circle in red then the you will get additional information as noted below.
3. The above information shows alternatives options that are a better price. As you can see here the suggestion is to prescribe the patient 3 months worth of Tirzeptatide as it will only cost $262 per month if it is prescribed to CenterWell Pharmacy as a 3 month prescription instead of 1 month to Walgreens.
- Some insurance companies require step up therapy, which means they will require that patients try other diabetic medications prior to a GLP1RA or try semaglutide/liraglutide before start tirzepatide.
Dosing:
- Weekly dosing: Wegovy (semaglutide), Trulicity (dulaglutide), Zepbound (Tirzepatide), Mounjaro (tirzepatide)
- Daily dosing: Saxenda (liraglutide), Rybelsus (oral semaglutide)
Dose escalation:
- Weekly agents can be escalated monthly
- If patients are experiencing GI sides effects or losing weight rapidly (>1% body weight per week) then wait until the side effect subsides and the weight plateaus before increasing dose and would titrate more slowly
- Daily injected agents can be escalated weekly
- Daily oral agents (only Rybelsus (semaglutide) at the moment) are escalated every 30 days.
- Ozempic (semaglutide):
- One order can be used to escalate from 0.25 mg to 0.5 mg, but then a new order will be needed for the 1 mg dose because this is a new pen
- A new order will be needed for each dose escalation of the following because they use one time dose autoinjectors: Mounjaro (tirzepatide) for diabetes, Zepbound (tirzepatide) for weight loss Trulicity (dulaglutide), Wegovy (semaglutide) for weight loss
- Rybelsus (semaglutide:
- This is an oral tablet.
- The first prescription will need to be for 3 mg. Then there will need be an additional prescription after 30 days to increase dose to 7 mg. Per manufacturer’s website the dose can be increased further to 14 mg after being on 7 mg for 30 days if additional glycemic reduction is needed.
Goal doses:
- These aren’t set in stone, so it makes it a little difficult, but the goal is to get the patient to a dose that allows you to achieve good glycemic control (if diabetic) and weight loss (if overweight). It is a little less clear for CV risk reduction and kidney disease reduction.
- Rybelsus (oral semaglutide):
- Can stop at 7 mg if achieving good glycemic control and desired weight loss. If not, then can escalate to 14 mg daily.
- Mounjaro (tirzepatide) for diabetes:
- Max dose of 15 mg
- Consider stopping at 5 mg or 10 mg if achieving adequate weight loss and glycemic control.
- Zepbound (Tirzepatide) for weight loss:
- Max dose of 15 mg
- Consider stopping at 5 mg or 10 mg if achieving adequate weight loss and glycemic control.
- Ozempic (semaglutide)
- Max dose: 2 mg
- FLOW utilized a dose of 1 mg, but this was done before other trials that used 2 mg. So again would try to at least get patients to 1 mg, but then if they do not have side effects and desire further weight loss would consider increasing to 2 mg.
- Wegovy (semaglutide)
- Max dose 2.4 mg
- If able to achieve appropriate weight loss then can stop at 1.7 mg, but if more weight loss is desired then would increase to 2.4 mg
- Saxenda (liraglutide)
- Max dose 3 mg
- If weight loss is not desired then target 1.8 mg
- If weight loss is desired then target 3.0 mg
- Trulicity (dulaglutide)
- Max dose 4.5 mg
- Can stop at 1.5 mg or 3.0 mg if achieving good glycemic control.
Additional thing to remember when ordering:
- These medications are ordered based on volume. Need to input the correct volume in the quantity field.
- For example for Ozempic (semaglutide), if you want to order four 1 mg doses then you need to order 3 mL in the quantity area because a 1 mg injection of Ozempic is 0.75 ml.
- Another example: Trulicity and Mounjaro come as 4 doses in a pack. For Mounjaro (tirzepatide), if you want to do 5 mg weekly then you need to look at the concentration which differ based on the dose. Specifically for 5 mg dosing the autoinjector’s concentration is 0.5 mg/0.5 ml so you will need to order 2 ml.
- If added to patients on insulin or sulfonylureas, GLP1RA can cause hypoglycemia.
- If diabetes is well controlled (ie HbA1c < 8% then lower insulin by 20-30% and/or consider stopping sulfonylurea)
- If diabetes is NOT well controlled then start GLP1RA without adjusting medications
- Other diabetes medications such as metformin can be left alone when starting GLP1RA even when diabetes is already well controlled
Training:
- Young patients can watch videos on manufacturer’s website to learn.
- The nurses in Clinic 1A are all trained to teach patients how to use the injectors so if a patient needs more help the nurses can be asked to do training.
What to watch out for:
- Recommend that patients keep hydrated. Patients sometimes will not drink water if they don’t have an appetite.
- Consider checking a renal function panel if patient reports side effects to be sure they do not develop an AKI in the setting of GI side effects for instance
- Be sure that for Ozempic (semaglutide) that the dial is twisted all the way to the point where the correct dose is being shown on the pen. If the patient is not twisting the dose pen appropriately then they will not get a full dose.
- Do NOT start if patient had uncontrolled retinopathy or maculopathy.
Side Effects:
- The gastrointestinal side effects tend to resolve after a few doses. For instance, nausea will usually go away after a few doses.
- Council on how to avoid nausea/vomiting. Explain that these medications will lead to slowed gastric emptying so patients should try to do smaller more frequent meals. Also avoiding meals that are heavy in fat and carbohydrate loads will be help reduce chance of experiencing nausea.
- Reports of increased risk of pancreatitis. If there is suspicion of pancreatitis, stop the GLP-1 receptor agonist. Then if pancreatitis is confirmed do not restart a GLP-1RA
VA GLP1-RA Prescriptions
NEW!!!!!! Weight loss meds update!!! semaglutide (Wegovy), tirzepatide (Zepbound), and liraglutide (Saxenda): LIMITED AVAILABILTY has just opened. Current eligibility criteria (to be updated quarterly):
- Documentation of a least one verifiable session in MOVE! Program or other qualifying comprehensive lifestyle intervention (CLI) within the last 12 months AND
- ONE of the following criteria:
-
- Has a life-threatening weight-related condition or experiencing treatment delay for a life-threatening condition due to excess weight for whom treatment delay would likely increase mortality risk within the next year (this would apply to very few Veterans) OR
- >45yrs old with established cardiovascular disease* (*defined here as previous MI, stroke, or symptomatic peripheral arterial disease) AND BMI >/= 35 but does NOThave T2DM
Note: Pts with T2DM might qualify for semaglutide for diabetes (Ozempic)
