CurrentCignaPolicy IP0702

Diabetes - Glucagon-Like Peptide-1 Agonists for Individual and Family Plans

Defines prior authorization, coverage criteria, and exclusions for specified GLP-1 receptor agonists and the GLP-1/GIP agonist for treatment of type 2 diabetes under Cigna Individual and Family Plans.

Policy Summary

PayerCigna

PolicyDiabetes - Glucagon-Like Peptide-1 Agonists for Individual and Family Plans

Policy CodePolicy IP0702

Change TypeOperational and product updates

Effective DateAug 15, 2025

Next Review Date

Key ActionObtain prior authorization and submit documentation supporting a diagnosis of type 2 diabetes for approvals (typically granted for 1 year).

SourceLink

POLICY UPDATE CHANGES

Removed the metformin requirement from all products.

Removed preferred product requirements from liraglutide, Mounjaro, Ozempic and Rybelsus.

Added generic exenatide to the policy to follow Byetta criteria.

Prior authcoverage process

1 yearapproval duration

7targeted products

Weight loss, T1Dexplicit exclusions

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

Initial Therapy (Product-specific approvals)

Covered when the following are met for the specified products

Bydureon BCise, exenatide, liraglutide, Mounjaro, Ozempic, and Trulicity: Approve for 1 year if the patient has a diagnosis of type 2 diabetes mellitus.

Documentation required to support diagnosis and duration of therapy.

Rybelsus specific: Approve for 1 year if patient is >=18 years and has a diagnosis of type 2 diabetes mellitus.Age >= 18

Documentation required.

Victoza specific: Approve for 1 year if patient has a diagnosis of type 2 diabetes mellitus AND preferred product criteria is met.

Preferred product criteria: patient has tried bioequivalent generic liraglutide and cannot take it due to formulation differences causing significant allergy or serious adverse reaction per prescriber (see product-specific preferred criteria table).

The following uses of GLP-1 receptor agonists and the GLP-1/GIP agonist are not medically necessary and are excluded from coverage: treatment for weight loss in patients without type 2 diabetes, therapy for type 1 diabetes mellitus, use for prediabetes/diabetes prevention, management of metabolic syndrome in the absence of type 2 diabetes, and concomitant use of more than one GLP-1 or GLP-1/GIP agent simultaneously.

GLP-1 agents addressed in this policy are not approved for chronic weight management in patients who are overweight (BMI ≥ 27 kg/m2) or obese (BMI ≥ 30 kg/m2) unless the patient has type 2 diabetes; products that are specifically indicated for weight loss (for example, Saxenda, Wegovy, Zepbound) are separate and not covered under these type 2 diabetes indications. The policy follows guideline guidance discouraging off‑label use of GLP-1 receptor agonists solely for weight loss.

None of the GLP-1 or GLP-1/GIP agents in this policy are indicated for type 1 diabetes. Evidence shows only minimal A1c benefit when GLP-1 agonists are added to insulin in type 1 diabetes, and such use is considered not medically necessary.

For patients with elevated blood glucose but without type 2 diabetes, GLP-1 or GLP-1/GIP therapy for prediabetes/diabetes prevention is not indicated; first-line prevention remains lifestyle modification and, where appropriate, metformin. Similarly, metabolic syndrome without a diagnosis of type 2 diabetes is not an accepted indication for these agents under this policy.

The GLP-1 and GLP-1/GIP agents should not be used in combination with one another or with any other GLP-1 class agent; concomitant use of multiple GLP-1/GLP-1-GIP products is considered not medically necessary.

Coding Guidance

Guidance on coding usagemixed

No codes listed

Provider Requirements and Authorization Process

Prior Authorization

Prior Authorization Required

Prior Authorization is required for benefit coverage of the GLP-1 agonists and GLP-1/GIP agonist targeted in this policy. All approvals are provided for the duration noted in the policy. Claims submitted for services that are not accompanied by covered code(s) under the applicable Coverage Policy will be denied as not covered. Receipt of sample product does not satisfy any criteria requirements for coverage.

Prior authorization required for GLP-1 and GLP-1/GIP agonists (see policy for approved duration)
Claims without covered diagnosis/procedure codes will be denied as not covered
Receipt of sample product does not satisfy criteria requirements for coverage

Documentation Required

Required Documentation

Documentation is required to support medical necessity and must be submitted with the prior authorization request. Acceptable documentation may include, but is not limited to, chart notes, laboratory results, and claims records. For products with specific documentation flags in the criteria (e.g., "[Documentation Required]"), include the exact clinical information requested (diagnosis details, prior medication trials, age when required, and any prescriber attestation).

Background

GLP-1 receptor agonists and the GLP-1/GIP agonist are indicated as adjuncts to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Clinical guidelines (for example, the American Diabetes Association Standards of Care and KDIGO) recommend GLP-1 receptor agonists particularly when a patient has comorbid atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease, and agent selection may be influenced by comorbidities and weight management goals.

Approvals under this policy are product-specific and require prior authorization; when criteria are met the agents are typically approved for 1 year. Documentation such as chart notes, laboratory results, and claims records must support the diagnosis of type 2 diabetes and any other stated criteria for approval.

Definitions

GLP-1/GIP agonist (e.g., tirzepatide — Mounjaro)

ClassGLP-1/GIP agonist (example: tirzepatide — Mounjaro). Agonist of both GLP-1 and GIP receptors used as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes.

Indications noted in policyIndicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes; subject to prior authorization per policy.

Pediatric notePolicy notes that some agents in the overall class have pediatric indications (≥10 years) but tirzepatide-specific pediatric use is not asserted in the source text.

GLP-1 agonist (e.g., semaglutide, liraglutide, dulaglutide, exenatide)

ClassGlucagon-like peptide-1 (GLP-1) receptor agonists (examples: semaglutide, liraglutide, dulaglutide, exenatide). Agents that mimic GLP-1 to improve glycemic control as adjuncts to diet and exercise in adults with type 2 diabetes.