CurrentCignaPolicy N/A

Glucagon-Like Peptide-1 Agonists Drug Quantity (Claim Per Days) limits

Defines claim-level quantity limits and one-time override rules for GLP-1 and GLP-1/GIP agonist products administered under Cigna health benefit plans; applies to retail and home delivery claims for the listed products.

Policy Summary

PayerCigna

PolicyGlucagon-Like Peptide-1 Agonists Drug Quantity (Claim Per Days) limits

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionClaim Per Days quantity limits apply and may be enforced for GLP-1 and GLP-1/GIP agents; approvals are provided for the duration noted in the policy and any exception is considered not medically necessary unless criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

9products listed

one-timeone-time override

28-daysupply threshold

New Policyreview status

Coverage Criteria

One-time override criteria (by product)

Covered as medically necessary when ALL of the specific one-time override criteria below are met for the indicated product

Byetta overrides: Approve a one-time override for one additional claim of Byetta at retail or home delivery when switching between Byetta strengths OR when switching from another GLP-1 or GLP-1/GIP agonist to Byetta.one-time override

See note listing other GLP-1/GLP-1-GIP agents

Bydureon BCise overrides: Approve a one-time override for one additional claim of Bydureon BCise at retail or home delivery when switching from another GLP-1 or GLP-1/GIP agonist to Bydureon BCise.one-time override

See note listing other GLP-1/GLP-1-GIP agents

Policy Summary

PayerCigna

PolicyGlucagon-Like Peptide-1 Agonists Drug Quantity (Claim Per Days) limits

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Approve a one-time override for one additional claim of Mounjaro at retail or home delivery when switching between Mounjaro strengths OR when switching from another GLP-1 or GLP-1/GIP agonist to Mounjaro.

See note listing other GLP-1/GLP-1-GIP agents

Ozempic overrides: Approve a one-time override for one additional claim of Ozempic at retail or home delivery when switching between Ozempic strengths OR when switching from another GLP-1 or GLP-1/GIP agonist to Ozempic.one-time override

See note listing other GLP-1/GLP-1-GIP agents

Rybelsus overrides: Approve a one-time override for one additional claim of Rybelsus at retail or home delivery when switching between Rybelsus strengths OR when switching from another GLP-1 or GLP-1/GIP agonist to Rybelsus.one-time override

See note listing other GLP-1/GLP-1-GIP agents

Trulicity overrides: Approve a one-time override for one additional claim of Trulicity at retail or home delivery when switching between Trulicity strengths OR when switching from another GLP-1 or GLP-1/GIP agonist to Trulicity.one-time override

See note listing other GLP-1/GLP-1-GIP agents

Liraglutide (Victoza) overrides: Approve a one-time override for one additional claim of liraglutide SC injection (Victoza, authorized generic) at retail or home delivery when switching from another GLP-1 or GLP-1/GIP agonist to Victoza.one-time override

See note listing other GLP-1/GLP-1-GIP agents

Other exceptions beyond the specified one-time overrides are considered not medically necessary. The Claim Per Days quantity limits apply to the listed GLP-1 and GLP-1/GIP products and are enforced for claims that meet the claim supply threshold (see Coding). Refer to Appendix A for the full list of drugs included in this limit; the rule only applies to claims for ≥ 28-day supply. Any coverage for additional claims must meet the specific one-time override criteria described in this policy.

Any exception to the Claim Per Days quantity limits that is not specifically addressed by the listed one-time override criteria is considered not medically necessary. Approvals beyond the per-claim limits will only be granted when the documented situation matches one of the product-specific one-time override conditions in this policy.

Coding & Claim Thresholds

Claim supply threshold — applies to claims for ≥ 28-day supply

Claim supply thresholdThis Claim Per Days quantity limit rule applies to claims for ≥ 28-day supply.

Applies to which productsGLP-1 and GLP-1/GIP agonist products listed in Appendix A and addressed by this policy.

EnforcementAny exception outside listed one-time overrides is considered not medically necessary and may be denied for claims meeting the ≥28-day threshold.

Provider Actions & Billing Rules

Documentation Required

Coverage determination guidance

Coverage determinations require consideration of the applicable benefit plan terms, any applicable laws and regulations, relevant collateral source materials (including coverage policies), and the specific facts of the particular situation. Each coverage request should be reviewed on its own merits; medical directors are expected to exercise clinical judgment and have discretion in making individual coverage determinations. In the event of a conflict, the customer's benefit plan document supersedes the coverage policy. Delegated vendor guidelines may be used to support medical necessity and other coverage determinations in certain markets.

Consider the terms of the applicable benefit plan document in effect on the date of service
Consider any applicable laws and regulations
Consider relevant collateral source materials (including coverage policies and delegated vendor guidelines where applicable)
Review each coverage request on its own merits and document clinical rationale

Billing Rule

Claim Per Days limits apply

Claim Per Days quantity limits apply — Claim Per Days quantity limits apply and may be enforced for GLP-1 and GLP-1/GIP agents; approvals are provided for the duration noted in the policy.

Billing Rule

Quantity limits interaction

Quantity limits interaction — The Claim Per Days quantity limits can be applied alone or with standard per-product Per Days limits. For details regarding each product's Per Days quantity limits, refer to each respective Per Days Drug Quantity Management policy.

Denial Risk

Denial trigger

Denial trigger — Any exception to the Claim Per Days quantity limits is considered not medically necessary.

Background

Glucagon-like peptide-1 (GLP-1) receptor agonists and GLP-1/GIP agonists are used as adjuncts to diet and exercise to improve glycemic control in patients with type 2 diabetes; product labeling for some agents includes pediatric or cardiovascular risk reduction indications. These agents are administered subcutaneously and are subject to the program’s quantity-management rules. They should not be combined with each other or with any other GLP-1 or GLP-1/GIP agonists. The policy’s Claim Per Days limits are intended to promote safe, effective, and economical use of these agents and are applied to claims meeting the supply threshold stated in this document.

Definitions

Combination use — do not combine GLP-1 / GLP-1-GIP agents

Combination use ruleGLP-1 agonists and GLP-1/GIP agonists should not be combined with each other or with any other GLP-1 or GLP-1/GIP agonists.

ScopeApplies to all GLP-1 and GLP-1/GIP agonists addressed in this policy (see Appendix A for full product list).

Clinical rationaleThese agents are indicated as adjuncts to diet and exercise for glycemic control; combining agents is not recommended.