GLP-1 MEDICATIONS AND ASEBP COVERAGE

What Are GLP-1 Medications?

GLP-1 stands for glucagon-like peptide-1, a naturally occurring hormone that helps regulate blood sugar, appetite and digestion. GLP-1 receptor agonists are medications that mimic the action of this hormone. They enhance insulin secretion in response to food, slow gastric emptying so a person feels full longer, reduce appetite and food intake, and support improved glucose control and weight loss.

These medications were originally developed to treat Type 2 diabetes. More recently, certain GLP-1 therapies have been approved specifically for chronic weight management. Under the Alberta School Employee Benefit Plan (ASEBP), some GLP-1 medications are eligible for coverage through a special authorization process when prescribed for weight management.

In recent weeks, questions have arisen about whether coverage is limited to two years, whether comorbidities must persist after weight loss in order to continue coverage, and what happens if weight is regained. ASEBP has provided clarification, and the information here reflects the current criteria.

Is Coverage Limited to Two Years?

There is no automatic two-year cut-off for GLP-1 medications under ASEBP’s weight management criteria. Coverage may continue indefinitely, provided that a member achieves at least 5 per cent weight loss after starting the therapy and maintains that reduction at yearly renewals. Confusion about a two-year limit stemmed from a misunderstanding of the applicable criteria. The plan does not impose a time-based limit if the clinical benefit is demonstrated and maintained. 

What Constitutes a Trial?

Under ASEBP’s special authorization framework, coverage for GLP-1 medications begins with a trial period. During that period, the member must lose at least 5 per cent of their baseline body weight and continue the therapy without interruption. The trial concludes if the required weight loss is not achieved, if the weight loss is not maintained at renewal or if the therapy is stopped for any reason. If weight is regained, the trial ends.

How Many Trials Are Permitted?

Members are eligible for two lifetime trials per specific GLP-1 molecule. If a member has completed one trial with a medication, they may apply to begin a second trial with the same medication. If two trials with the same medication fail to meet or maintain the criteria, no further approvals will be granted for that molecule. However, the member may pursue an alternative GLP-1 medication if available and approved.

Currently, the GLP-1 medications with weight-management indications include Wegovy and Saxenda, although Saxenda is expected to be discontinued or replaced by generics. Zepbound is under review and may soon be subject to similar authorization criteria. As additional medications and generics enter the market, members who have exhausted trials with one molecule may gain access to others.

Are Comorbidities Required for Continued Coverage?

Feedback from the field has suggested that once a member reached their goal weight, they would need to continue demonstrating a comorbidity, such as sleep apnea, in order to remain covered. ASEBP has confirmed that this is not the case under its plan. If a member qualifies under the weight-loss indication, achieves and maintains the required 5 per cent weight reduction, and continues the therapy without interruption, their coverage will continue. The ongoing presence of the original comorbidity is not required in order to maintain authorization under the weightmanagement pathway.

What About Diabetes-Related Use?

GLP-1 medications are also prescribed for Type 2 diabetes. In those circumstances, different clinical criteria apply. The information outlined here relates specifically to weight-management coverage and should not be interpreted as applying to diabetes-related authorizations.

An Evolving Area

The use of GLP-1 medications for weight management is a rapidly evolving area. New therapies are entering the market; generics are anticipated; and special authorization criteria may be adjusted as evidence, utilization patterns and pricing change. ASEBP has indicated that this area remains a priority and that members will be updated as developments occur.

WORTH SHARING

There is no automatic two-year limit on GLP-1 coverage for weight management under ASEBP. Coverage can continue indefinitely if a member loses at least 5 per cent of their starting weight and maintains that reduction at annual renewals. ASEBP allows two lifetime trials for each medication, and a trial ends if weight-loss criteria are not met, weight is regained or the therapy is stopped. Continued coverage does not require the ongoing presence of a comorbidity once weight loss has been achieved and maintained.

If you have questions about your specific circumstances, contact ASEBP directly to review your file and authorization history. If you have questions relating to a denial of access to a medication and possible appeal mechanisms, please contact Teacher Employment Membership Support at 1800-232-7208.

Read the full Worth Knowing. 

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