Some Wegovy prescriptions redirected to pharmacies that signed exclusive deals with insurers

Some patients who take the popular weight-loss drug Wegovy are having their prescriptions redirected to pharmacies that have signed exclusive deals with their group benefit insurers, the most high-profile example yet of a controversial industry practice called preferred pharmacy networks, or PPNs.

Pharmacists in both Alberta and Ontario told The Globe and Mail about multiple incidents where drug claims for Wegovy have been rejected by insurance companies for reimbursement under group benefit plans. In most cases, pop-up messages at pharmacy checkouts alert patients that they have to contact a preferred pharmacy in order to receive their medication.

Insurers argue that they create PPNs to ensure certain service standards and to control costs for plan sponsors by negotiating lower pharmacy markups and fees. Pharmacies – particularly independent ones left out of networks – argue the exclusivity deals reduce patient autonomy and can leave patients filling prescriptions at multiple different pharmacies, depending on how the PPNs treat each drug.

The Ontario government recently proposed options to regulate PPNs and has carried out two public consultations in the past year.

PPNs are most commonly used for what insurers call “specialty drugs.” While there is no universal industry definition of a specialty drug, it typically refers to high-cost drugs that can cost $10,000 or more a year. Insurers often say only a single-digit percentage of plan members take these drugs and are affected by PPN arrangements.

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Ozempic and Wegovy – two related products made by Danish drug maker Novo Nordisk NVO-N primarily to treat diabetes and obesity – are different from other specialty drugs in that they are much cheaper, costing a few hundred dollars a month.

But they can contribute significantly to a plan sponsor’s costs because they are high-volume. Ozempic is by far the bestselling prescription drug in Canada, with sales of more than $2.5-billion at retail pharmacies last year, nearly triple the next bestselling drug.

Many plan advisers – who help employers negotiate the renewal of group benefit plans – say the sharp rise in usage of these drugs is putting serious pressure on drug-plan sustainability. Some companies have already set maximum coverage limits.

Joelle Walker, executive vice-president of strategy, operations and public affairs at the Canadian Pharmacists Association, said the fact that such a popular drug is now being caught up in PPNs is concerning.

“The goalposts keep changing” for what is considered a specialty drug, she said.

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GreenShield Canada, which offers group benefit insurance plans, recently moved Wegovy into its closed PPN, which means that patients on the drug will have their claims reimbursed only if they buy it at in-network pharmacies.

“Wegovy significantly increases total plan costs, due to the combination of its price and very high utilization,” GreenShield spokesperson Mandy Mail said.

The insurer said Wegovy claims were, on average, $5,100 annually a patient, more than five times higher than the average drug claimant.

Ms. Mail also said GreenShield will reassess the policy when cheaper generics hit the market in Canada next year.

Bruce Winston, senior director of advocacy at Neighbourly Pharmacy, a national chain, said a patient at one of its Alberta pharmacies recently had their prescriptions steered away by a mail-order pharmacy run by Express Scripts Canada. The patient, who has drug insurance through Sun Life Financial Inc. SLF-T, has diabetes and has been working with an Alberta pharmacist who is also a certified diabetes educator.

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Shortly after being prescribed Wegovy, the patient was contacted by Express Scripts Canada asking to transfer the Wegovy prescription to an Express Scripts pharmacy in order to save money. When the patient declined, they were told their insurance plan required the patient to fill their gastric inhibitory polypeptide and GLP-1 type prescriptions at an Express Scripts pharmacy.

“Initially, PPNs were concentrating on specialty high-cost drugs, but within the last few years, and for sure within mail-order pharmacies, it’s gone well beyond high-cost drugs to regular medications,” Mr. Winston said in an interview.

Sun Life said it does not require Wegovy prescriptions (or any other medication) to be filled only at a pharmacy in its preferred network. In response to a question about the Alberta patient at a Neighbourly Pharmacy, Sun Life said it did not have the details of that case but that it could be because of how the patient’s employer designed their drug plan.

Express Scripts Canada did not respond to a request for comment.

The Globe also asked the two other biggest Canadian private health insurers – Manulife MFC-T and Canada Life LFE-T – if Wegovy or Ozempic were part of their PPNs.

Canada Life said it does not include Wegovy under its Health Case Management plan, the name it applies to its PPN. Manulife said Wegovy is not part of any closed PPN, although plan sponsors have control over their plan designs.

Novo Nordisk did not respond directly to questions about whether the company is aware of its products being directed through PPNs, but said it is “focused on improving access” to its medicines.

“Novo Nordisk Canada supplies products to wholesalers for distribution to pharmacies and then to patients,” senior director of communications Kate Hanna said in an e-mail.