CurrentCignaPolicy IP0702

Diabetes – Glucagon-Like Peptide-1 Agonists for Individual and Family Plans - (IP0702)

Cigna coverage policy for select GLP-1 receptor agonists and a GLP-1/GIP agonist for treatment of type 2 diabetes in Individual and Family Plans, specifying prior authorization, approved indications, age limits, required documentation, product-specific preferred-product criteria for Victoza, and exclusions (non-covered uses).

Policy Summary

PayerCigna

PolicyDiabetes – Glucagon-Like Peptide-1 Agonists for Individual and Family Plans - (IP0702)

Policy CodePolicy IP0702

Change TypeRevisions including removals of metformin and preferred-product requirements; added generic exenatide

Effective DateApr 1, 2026

Next Review Date

Key ActionPrior Authorization is required for benefit coverage of the GLP-1 and GLP-1/GIP products listed in this policy; providers must submit documentation supporting a diagnosis of Type 2 diabetes and use covered diagnosis/procedure codes.

SourceLink

POLICY UPDATE CHANGES

Removed the metformin requirement from all products.

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

Updated the Victoza preferred product requirement to a Multi-Source Brand approach.

Added generic exenatide to the policy to follow Byetta criteria.

Updated Conditions Not Covered: Prediabetes/Diabetes Prevention statement with ADA Standards of Care information.

Updated the Weight Loss Treatment statement under Conditions Not Covered.

7Products listed in policy

5Not-covered condition categories listed

1 yearTypical approval duration

Coverage Summary

Scope: Cigna coverage policy for select GLP-1 receptor agonists and a GLP-1/GIP agonist for treatment of Type 2 Diabetes in Individual and Family Plans, specifying prior authorization, approved indications, age limits, required documentation, product-specific criteria, and exclusions. Coverage stance: covered_with_criteria. Effective date: 04/01/2026; Last review: 04/01/2026. Coverage aligns to FDA-approved indications and clinical guidance including the American Diabetes Association Standards of Care 2026.

Key policy facts

Products listed in policy7

Typical approval duration1 year

Not-covered condition categories listed5

Policy numberIP0702

PayerCigna Companies (Individual and Family Plans)

Effective date04/01/2026

Last review date04/01/2026

Initial Therapy Criteria

Medically Necessary – Bydureon BCise, exenatide (Byetta/generic), liraglutide (Victoza/generic), Mounjaro, Ozempic, Trulicity

Approve for 1 year if the patient meets the following:

ALL of the following

Diagnosis of Type 2 diabetes mellitus
Documentation Required

Medically Necessary – Rybelsus

Approve for 1 year if the patient meets BOTH of the following:

ALL of the following

Patient is 18 years of age or older
Diagnosis of Type 2 diabetes mellitus

Victoza Preferred-Product Criteria

Individual and Family Plans – Victoza preferred product criteria

Victoza criteria

ALL of the following

The patient has tried liraglutide subcutaneous injection (the bioequivalent generic product) AND cannot take due to a formulation difference in the inactive ingredient(s) (for example, difference in dyes, fillers, preservatives) between the brand and the bioequivalent generic product
Prescriber must state that the difference would result in a significant allergy or serious adverse reaction

Prior Authorization & Documentation Requirements

Prior Authorization and Documentation

Policy-level requirements

ALL of the following

Prior Authorization is required for benefit coverage of the GLP-1 agonists and GLP-1/GIP agonist targeted in this policy
Documentation is required as noted in the criteria
May include chart notes, laboratory results, claims records, and/or other information

Prior Authorization

Prior authorization required

Prior Authorization is required for benefit coverage of the GLP-1 and GLP-1/GIP products listed in this policy; approvals are provided for the duration noted (generally 1 year).

Conditions Not Covered (Exclusions)

Conditions Not Covered (Not Medically Necessary)

GLP-1 agonists and GLP-1/GIP agonist are not covered for any use other than the FDA-approved indications listed above, including but not limited to:

ANY of the following

Weight Loss Treatment for patients without type 2 diabetes (e.g., Saxenda, Wegovy, Zepbound and other GLP-1 products indicated for weight loss)
Not covered for overweight (BMI ≥ 27 kg/m2) or obese (BMI ≥ 30 kg/m2) patients without type 2 diabetes
Type 1 Diabetes Mellitus
None of the GLP-1 or GLP-1/GIP agonists in this policy are indicated for type 1 diabetes
Prediabetes/Diabetes Prevention
Not indicated for patients with elevated blood glucose who do not have type 2 diabetes

Applicable Products / Examples

Policy targeted products (by brand/generic names listed in policy text)mixedCovered

Bydureon BCise	exenatide extended-release subcutaneous injection (AstraZeneca) - noted obsolete 03/31/2025
Byetta	exenatide subcutaneous injection (AstraZeneca) - brand obsolete 03/06/2025; generic exenatide added to policy
Mounjaro	tirzepatide subcutaneous injection (Eli Lilly)
Ozempic	semaglutide subcutaneous injection (Novo Nordisk)
Rybelsus	semaglutide tablets (Novo Nordisk)
Trulicity	dulaglutide subcutaneous injection (Eli Lilly)
Victoza	liraglutide subcutaneous injection (Novo Nordisk) and generic liraglutide

Examples of products explicitly NOT targeted/covered under this diabetes policy (weight-loss indicated products)mixedNot Covered

Saxenda	liraglutide subcutaneous injection for chronic weight management (not indicated for diabetes in this policy)
Wegovy	semaglutide tablet and subcutaneous injection for chronic weight management
Zepbound	tirzepatide subcutaneous injection for chronic weight management

Background & Evidence

GLP-1 receptor agonists and the GLP-1/GIP agonist addressed in this policy are indicated as adjuncts to diet and exercise to improve glycemic control in adults with Type 2 Diabetes. Several agents have additional labeled indications (for example, pediatric indications for patients ≥ 10 years and cardiovascular or renal-related indications) per the prescribing information. Coverage decisions in this policy are aligned with FDA-approved indications and the American Diabetes Association Standards of Care 2026.

Evidence and guideline sources informing this policy: American Diabetes Association Standards of Care 2026; American Association of Clinical Endocrinology comprehensive type 2 diabetes management statement (2023).

Definitions

Documentation Required: May include chart notes, laboratory results, claims records, and/or other information to support the diagnosis of Type 2 diabetes mellitus and medical necessity as noted in product-specific criteria.

Revision History

10/10/2024 (effective 02/13/2025)revised

Removed the metformin requirement from all products.

12/01/2024 (effective 04/01/2025)revised

Removed the metformin requirement from all products.

10/10/2024 (effective 02/13/2025)revised

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

Policy Summary

PayerCigna

PolicyDiabetes – Glucagon-Like Peptide-1 Agonists for Individual and Family Plans - (IP0702)

Policy CodePolicy IP0702

Change TypeRevisions including removals of metformin and preferred-product requirements; added generic exenatide

Effective DateApr 1, 2026

Next Review Date

SourceLink

On This Page

Documentation Required

Medically Necessary – Victoza (liraglutide)

Approve for 1 year if the patient meets BOTH of the following:

ALL of the following

Diagnosis of Type 2 diabetes mellitus
Documentation Required
Preferred product criteria is met for the product(s) as listed in the table for Individual and Family Plans

Documentation Required

Documentation required

Providers must supply documentation supporting diagnosis of Type 2 diabetes mellitus (may include chart notes, laboratory results, claims records, and/or other information) as indicated in product-specific criteria.

Documentation Required

Victoza preferred product documentation

For Victoza on Individual and Family Plans, the prescriber must document that the patient tried the bioequivalent generic liraglutide and cannot take it due to a formulation difference in the inactive ingredient(s) (for example, dyes, fillers, preservatives) which, per the prescriber, would result in a significant allergy or serious adverse reaction.

Billing Rule

Use covered diagnosis/procedure codes

Reimbursement is only provided if requested services are submitted with covered diagnosis and/or procedure code(s); claims submitted without covered codes under the policy will be denied as not covered.

Metabolic Syndrome without type 2 diabetes

Not indicated for metabolic syndrome without type 2 diabetes

Concomitant use with another GLP-1 agonist or GLP-1/GIP agonist

Products should not be combined with each other or with any other GLP-1 or GLP-1/GIP agonist

Clarification: Products that are indicated for chronic weight management—such as Saxenda (liraglutide), Wegovy (semaglutide), and Zepbound (tirzepatide)—are examples of GLP-1/GLP-1/GIP agents that are not targeted or covered under this diabetes policy when used for weight loss in patients without type 2 diabetes.

12/01/2024 (effective 04/01/2025)revised

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

10/10/2024 (effective 02/13/2025)revised

Updated the Victoza preferred product requirement to a Multi-Source Brand approach.

12/01/2024 (effective 04/01/2025)revised

Updated the Victoza preferred product requirement to a Multi-Source Brand approach.

10/10/2024 (effective 05/01/2025)added

Added generic exenatide to the policy to follow Byetta criteria.

12/01/2024 (effective 06/01/2025)added

Added generic exenatide to the policy to follow Byetta criteria.