Fraud Risks Involving Oral GLP-1 Therapies and Wegovy 

As the market for GLP-1 weight loss medications continues to expand, the introduction of oral formulations has created new opportunities for fraud, waste, and abuse (FWA). While oral GLP-1 therapies may improve patient access and convenience, they also introduce additional pharmacy benefit vulnerabilities, particularly when used alongside injectable products such as Wegovy. 

Health plans, PBMs, and pharmacy integrity teams should closely monitor overlapping oral and injectable GLP-1 utilization, as well as prescribing patterns involving telehealth providers, multiple pharmacies, and rapid therapy transitions. Emerging schemes suggest that bad actors are adapting existing pharmacy fraud tactics to capitalize on the growing demand for weight loss medications. 

Duplicate Therapy and Overlapping GLP-1 Utilization 

One of the most significant emerging risks involves members receiving both oral and injectable GLP-1 medications during the same treatment period. 

While brief overlap may occur during a legitimate transition from an oral GLP-1 therapy to an injectable product, recurring or prolonged overlap may indicate duplicate therapy, stockpiling, diversion, or other inappropriate utilization patterns. 

How to Spot Potential Duplicate Therapy 

Consecutive Overlap Periods 

Track members with active days’ supply for both oral and injectable GLP-1 therapies simultaneously. 

Look for: 

  • Patients receiving both oral and injectable GLP-1 medications within a 30-day period. 
  • Continued refilling of both therapies beyond the expected transition period. 
  • Overlapping days’ supply that extends into subsequent months without evidence that one therapy has been discontinued. 

Example: 
A patient receives a 30-day supply of an oral GLP-1 medication and fills a Wegovy prescription two weeks later. While a short overlap may be clinically appropriate, continuing to refill both medications in the following month should prompt review. 

Repeated Overlap Events 

A single transition period may be clinically appropriate. However, repeated overlap events over time may indicate a pattern that warrants further investigation. 

Look for: 

  • Two or more overlap periods within a 12-month period. 
  • Repeated switching between oral and injectable GLP-1 therapies. 
  • Multiple active GLP-1 prescriptions with recurring periods of overlap. 
  • Continued overlap after prior interventions or member outreach. 

Early Refills or Excessive Refills 

Refill patterns can provide valuable insight into potential stockpiling or inappropriate utilization. 

Look for: 

  • Medications consistently refilled at the 75% utilization threshold. 
  • Frequent early refills of either oral or injectable products. 
  • Automatic refill enrollment resulting in continued dispensing of a therapy that should have been discontinued. 
  • Accumulating days’ supply across multiple fills. 

Multiple Prescribers 

Patients may obtain oral and injectable GLP-1 medications from different prescribers, creating the appearance of separate treatment plans. 

Look for: 

  • Prescriptions written on the same date or within a short timeframe by different providers. 
  • Prescriptions from both a primary care provider and a telehealth weight-loss service. 
  • Multiple prescribers treating the same patient without evidence of care coordination. 
  • High-volume telehealth providers prescribing GLP-1 therapies alongside existing treatment regimens. 

Multiple Pharmacies 

Utilizing multiple pharmacies can make duplicate therapy more difficult to identify and may indicate fragmented care or intentional pharmacy shopping. 

Look for: 

  • Oral medications filled at one pharmacy and injectable medications filled at another. 
  • Different GLP-1 products obtained through retail, mail-order, or specialty pharmacies. 
  • Different strengths or formulations filled at separate locations. 
  • Simultaneous use of local and out-of-area pharmacies. 

Duplicate therapy is often one of the earliest detectable indicators of broader fraud, waste, and abuse activity. Members receiving overlapping oral and injectable GLP-1 medications may be engaged in stockpiling, diversion, doctor shopping, prior authorization circumvention, or other inappropriate utilization practices. 

Implementing overlap-based monitoring, combined with reviews of prescriber, pharmacy, and refill activity, can help organizations identify emerging risks before significant pharmacy expenditures accumulate and before improper utilization becomes entrenched. 

How can Fraud Scope assist health plans with identifying potential overlaps for GLP-1 therapy drugs? 

Fraud Scope has pharmacy AI detection models that identify patients and providers with overlapping therapies, as well as GenAI query tools to search user-defined scenarios. Our partners can search Fraud Scope’s Top Codes section in Schemes for NDC codes related to GLP-1 therapies to identify their overall exposure and then drill down on the reasons to pinpoint the detector models and providers associated with the overlapping GLP-1 therapies. Should our health plan partners identify a novel group of pharmacy claims across multiple providers, patients written and fill dates, AI Query offers natural language so users can define the scenarios associated with the overlapping GLP-1 therapies.