Prior authorization guideline — Liraglutide (generic)
Customize your policy alerts
Sign up for all careoregon policy alerts
Know when careoregon releases new policies or updates existing guidance.
Monitor payer policy activity
Prior authorization guideline for liraglutide (generic) covering multiple indications including type 2 diabetes, chronic kidney disease, and diabetes with obstructive sleep apnea for CareOregon Medicaid members.
Changed guideline type from PA to Step.
Coverage Criteria
Type 2 Diabetes with Obstructive Sleep Apnea
Covered when ALL of the following are met:
From chunks 7 and 3.
Type 2 Diabetes - general criteria
Covered when ALL of the following are met:
From chunks 3 and 4.
Chronic Kidney Disease
Covered when ALL of the following are met:
From chunks 5 and 6.
No explicit exclusions are listed in this prior authorization guideline.
The policy does not specify items described as "not medically necessary."
Coding and Clinical Thresholds
| 2717005000D220 | LIRAGLUTIDE SOLN PEN-INJECTOR 18 MG/3ML (6 MG/ML) - Generic (GPI) |
Provider Actions & Authorization Rules
Prior authorization (step therapy) required for generic liraglutide
Prior authorization (step therapy) is required for the generic liraglutide product (GPI 2717005000D220) and indication-specific criteria must be met before approval.
Step therapy — required prior trials or documented contraindications
Step therapy requires documented trials and failures of specified alternatives or a documented contraindication/intolerance prior to approval.
- For general type 2 diabetes: trial and failure of an SGLT2 inhibitor or a DPP-4 inhibitor (or if ASCVD present, failure/contraindication/intolerance to an SGLT2 inhibitor).
- For type 2 diabetes with OSA: trial of and continuation of metformin, or documented failure/contraindication/intolerance to metformin.
- For chronic kidney disease: failure, contraindication, or intolerance to an SGLT2 inhibitor is required.
Required supporting documentation (medical records/chart notes)
Submit medical records or chart notes that demonstrate the clinical thresholds and required evaluations relevant to the requested indication.
- For CKD: documentation of stage 2–4 CKD, or eGFR 25–75 mL/min/1.73m2, or uACR > 30 mg/g.
- For diabetes with OSA: polysomnography confirmation of moderate–severe OSA and records showing either maximized positive airway pressure therapy or inability to tolerate such therapy.
- For diabetes with OSA: documentation of BMI > 30 kg/m2 and a weight-loss treatment plan ≥3 months within the past 6 months.
Denial triggers — missing prior trials or clinical documentation
Requests may be denied if required prior therapy trials, contraindications/intolerance, or clinical documentation for the selected indication are not provided.
- Missing documentation of trial and failure of an SGLT2 or DPP-4 inhibitor when required (or SGLT2 failure/contraindication when ASCVD present).
- For diabetes with OSA, absence of a metformin trial or documentation of metformin contraindication/intolerance when applicable.
- Insufficient evidence of CKD staging, eGFR/uACR values, OSA confirmation, BMI > 30 kg/m2, or failure/intolerance statements for positive airway pressure therapy.
Initial Therapy Requirements
Initial therapy requirements
Initial authorization requires demonstration of prior therapy trials or documented contraindications/intolerance as specified below:
From chunks 3, 4, and 7.
Step Therapy
| Step | Requirement | Provider action |
|---|---|---|
| 1 | ||
| Step therapy applies: prior trial and documented failure OR documented contraindication/intolerance to the specified alternative therapies before approval (e.g., for general Type 2 diabetes: trial and failure of an SGLT2 inhibitor or a DPP-4 inhibitor; for Type 2 diabetes with OSA: trial of and continuation of metformin or documented failure/contraindication/intolerance to metformin). | ||
| Document the prior trial(s) and outcome(s) or a documented contraindication/intolerance in the medical record and submit chart notes with the prior authorization request; lack of this documentation may result in denial. |
Definitions and Documentation
Background
Liraglutide is a GLP-1 receptor agonist used for glycemic control in type 2 diabetes and has evidence for weight reduction. This guideline applies step therapy expectations and requires indication-specific clinical documentation (for example, prior trials of specified alternatives for diabetes and measurable thresholds for comorbid conditions) before authorization is approved.
Revision History
Changed guideline type from PA to Step (operational change to step therapy requirement).
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.