How Diagnosis Verification and Audit Power Enables Smart GLP-1 Diabetes Management

The demand for GLP-1s isn’t slowing down, and neither is the pressure on plan sponsors to balance appropriate access with responsible cost management. Over time, the question has shifted from “Should we cover GLP-1s?” to “How do we cover them in a way that’s clinically sound and sustainable?” For most plan sponsors, the answer starts with the Diabetes Management Path, part of our new GLP-1 Pathways solution. 

Instead of leaning on upfront prior authorization (PA) for every member, the Diabetes Management Path pairs two coordinated clinical checks: Diagnosis Verification and Diagnosis Audit. Together, they provide strong clinical validation while supporting appropriate access and better experiences for members and providers. 

Verify Access at the Point of Sale

When a GLP-1 prescription is submitted, Automated Diagnosis Verification confirms type 2 diagnosis information at the point of sale. For appropriately coded claims, this creates a more streamlined path to therapy without requiring an upfront PA. Rather than relying on prescriber attestation alone, diagnosis information can be validated as part of the claims process, meaning a more direct path to therapy for eligible members. 

Deeper Clinical Validation

Diagnosis Audit strengthens initial diagnosis verification through a comprehensive review by our in-house clinical team. They review pharmacy claims, PA records, medical data and other available clinical information to further validate appropriate use and conduct targeted outreach to support the review when additional information is needed. Members with a confirmed diagnosis continue therapy without disruption, and if coverage criteria aren’t met, the member is notified and supported with alternatives.

Together, our Diagnosis Verification and Diagnosis Audit provide evidence-supported clinical validation, rather than relying solely on prescriber confirmation.

Supporting Access While Preserving Value

This approach is designed to meet three priorities which, when combined, balance strong clinical validation with a more streamlined experience for appropriately diagnosed members: 

1. Stronger clinical validation, going beyond attestation by using available claims and clinical information to validate appropriate therapy use. 
2. Better member and provider experiences, by streamlining access for appropriately coded claims without adding an additional upfront PA for every member. 
3. Preserving value by supporting broader rebate strategies, while helping avoid a potential 15%+ increase in net drug costs across the class.

Want to see the data behind this approach?

Explore our research on automated diagnosis verification for type 2 diabetes or connect with your Navitus representative to see how GLP-1 Pathways can support your plan’s needs. Learn more about GLP-1 Pathways.