CurrentBlue Cross Blue Shield - MassachusettsPolicy 056

GLP-1 and GIP/GLP-1 receptor agonist medications for type 2 diabetes

Prior authorization and medical necessity criteria for coverage of GLP-1 and GIP/GLP-1 receptor agonists (listed agents) for treatment of Type 2 Diabetes Mellitus for BCBSMA commercial plans; includes documentation and step/ formulary requirements and an individual consideration process.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyGLP-1 and GIP/GLP-1 receptor agonist medications for type 2 diabetes

Policy CodePolicy 056

Change TypeUpdated criteria and added indications/agents

Effective Date

Next Review Date

Key ActionSubmit prior authorization with documentation of prior trials or contraindications to formulary alternatives and required clinical records.

SourceLink

POLICY UPDATE CHANGES

Updated Rybelsus criteria to include expanded FDA indications.

Added Ozempic expanded indication for chronic kidney disease (CKD).

Added generic exenatide as a non-preferred agent.

12 monthsLength of approval

CommercialApplies to

~15Listed agents

RequiredPA requirements

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Coverage Criteria for GLP-1 and GIP/GLP-1 Agents

Initial Therapy (selected agents)

Covered when ALL of the following are met.

Overall: Member has Type 2 Diabetes Mellitus and requested medication is one of Mounjaro, Ozempic, Rybelsus, Trulicity, or Liraglutide; and additional criteria below must be met.

Age eligibility: Member meets ONE: age ≥10 years for Trulicity or Liraglutide; age ≥18 years for Ozempic, Rybelsus, or Mounjaro.

Concomitant therapy: Requested drug is not being prescribed for concurrent use with another GLP-1 or GLP-1/GIP receptor agonist.

Diagnostic confirmation: Has an ICD-10 or documented diagnosis of Type 2 Diabetes Mellitus confirmed by ONE of: HbA1c > 6.5%; Fasting plasma glucose ≥ 126 mg/dL after an 8-hour fast; 2-hour plasma glucose ≥ 200 mg/dL during a 75-g OGTT; Random plasma glucose ≥ 200 mg/dL with classic symptoms of hyperglycemia; or documented ICD-10 code for Type 2 Diabetes.A1c > 6.5% etc

Prior antidiabetic history or agent-specific qualifiers: Meets ONE: (a) history of antidiabetic medication use (e.g., insulin, sulfonylureas, metformin, SGLT-2 inhibitor, DPP‑4 inhibitor, or other); (b) history of intolerance, contraindication, clinically significant adverse effects, or inadequate response to metformin; (c) for Trulicity: documentation of chronic kidney disease (CKD) OR established atherosclerotic cardiovascular disease (ASCVD) OR at least two ASCVD risk factors; (d) for Liraglutide: documentation of established ASCVD; (e) for Ozempic: documentation of CKD OR established ASCVD; (f) for Rybelsus: history or documentation that the patient is at high risk for major cardiovascular events.

Per policy, agent-specific qualifiers required for certain agents.

Initial Therapy (other agents)

Covered when ALL of the following are met.

Overall: Member has Type 2 Diabetes Mellitus and requested medication is one of Adlyxin, Bydureon, Byetta, Exenatide, Soliqua, Victoza, or Xultophy; and additional criteria below must be met.

Age eligibility: Member meets ONE: age ≥10 years for Bydureon and Victoza; age ≥18 years for Adlyxin, Byetta, Soliqua, and Xultophy.

Concomitant therapy: Requested drug is not being prescribed for concurrent use with another GLP-1 or GLP-1/GIP receptor agonist.

Requests for any GLP-1 or GLP-1/GIP receptor agonist will be denied if the medication is prescribed for concurrent use with another GLP-1 or GLP-1/GIP receptor agonist. The requested drug must not be prescribed together with any other agent in this class to meet coverage criteria.

This concurrent-use prohibition is a required element of initial approval: it appears as a standalone criterion in the initial approval checklist and must be satisfied in addition to age, diagnosis, and prior-treatment requirements.

Requests supported solely by the use of manufacturer samples do not meet the policy’s coverage criteria. When prescription claims do not establish prior medication use, the provider must submit additional clinical documentation (for example, chart notes, lab results, or other relevant records) to demonstrate that the member meets the approval criteria.

For non-covered agents or when claims history is incomplete, the policy requires documentation of prior trials or contraindications to formulary alternatives; absence of objective documentation based only on samples is insufficient for approval.

Diagnosis and Diagnostic Thresholds

Diagnosis codesICD-10

ICD-10

Documented ICD-10 code for Type 2 Diabetes Mellitus (required)

Glycemic diagnostic thresholds — A1c and glucose thresholds for diabetes diagnosis

Hemoglobin A1c (HbA1c)> 6.5%

Fasting plasma glucose (FPG)≥ 126 mg/dL (post 8-hour fast)

2-hour plasma glucose (OGTT)≥ 200 mg/dL during a 75‑g oral glucose tolerance test

Random plasma glucose≥ 200 mg/dL with classic hyperglycemia symptoms (polyuria, polydipsia, polyphagia)

Alternative documentationDocumented ICD-10 diagnosis code for Type 2 Diabetes Mellitus

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization required — Prior authorization (PA) is required for the agents listed on the formulary (e.g., liraglutide, tirzepatide, semaglutide products, dulaglutide, exenatide products and others noted as PA/QCD). PA requests are reviewed by Pharmacy or Medical as appropriate. Providers may call Pharmacy Operations (Tel: 1-800-366-7778; Fax: 1-800-583-6289) or submit the Massachusetts Standard Form for Medication Prior Authorization Requests (eForm) or the Formulary Exception/Prior Authorization form. Failure to obtain PA when required may result in denial of coverage.

Pharmacy Operations: 1-800-366-7778; Fax: 1-800-583-6289
Use MA Standard Medication Prior Authorization eForm or Formulary Exception/Prior Authorization form
PA applies to agents listed as PA/QCD or PA in formulary table

Step Therapy

Step / Formulary Requirements

Step / formulary requirements — Requests must document a trial and inadequate response, intolerance, or contraindication to formulary alternatives. For coverage of non-preferred or non-formulary medications, the member must have had treatment failure with, or contraindication to, at least two covered formulary alternatives when available. Specific PA criteria for each agent (see formulary table) apply (e.g., documented trials of at least two covered GLP-1 or GLP-1–related formulary alternatives where required).

Definitions and Risk Factors

Atherosclerotic cardiovascular disease (ASCVD)

DefinitionAtherosclerotic cardiovascular disease (ASCVD) includes coronary heart disease (myocardial infarction, angina, coronary artery disease); cerebrovascular disease (transient ischemic attack, ischemic stroke); peripheral artery disease; and aortic atherosclerotic disease.

Examples — coronaryMyocardial infarction, angina, coronary artery disease

Examples — cerebrovascularTransient ischemic attack, ischemic stroke

Examples — peripheralPeripheral artery disease

ASCVD risk factors

DyslipidemiaAbnormal lipid profile (listed as an ASCVD risk factor)

Background

Glucagon-like peptide-1 (GLP-1) receptor agonists and dual GIP/GLP-1 receptor agonists are approved therapies for glycemic control in Type 2 Diabetes Mellitus. Several agents in this class carry additional cardiovascular or renal indications or are intended for specific age groups depending on the product.

This policy applies agent-specific eligibility and clinical qualifiers: approval requires documented Type 2 diabetes by glycemic criteria or ICD-10 diagnosis, age eligibility per agent (for example, age ≥10 for some agents such as Trulicity and Liraglutide and age ≥18 for others), and demonstration of prior antidiabetic therapy history or specific risk/diagnostic qualifiers (for example, CKD, established ASCVD, or high CV risk) as appropriate for the requested agent.

Policy Revision History

2026-03-15criteria_updateLatest

Updated Rybelsus criteria to include expanded FDA indications.

2025-08-01indication_added

Added Ozempic expanded indication for chronic kidney disease (CKD).

2025-09-15formulary_update

Added generic exenatide as a non-preferred agent.