CurrentCignaPolicy IP0702

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

Defines prior authorization, coverage criteria, and exclusions for specified GLP-1 and GLP-1/GIP agonists 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 TypeNew policy and multiple operational updates

Effective DateAug 15, 2025

Next Review Date

Key ActionSubmit prior authorization with documentation of Type 2 diabetes diagnosis to obtain coverage for GLP‑1 or GLP‑1/GIP agonists.

SourceLink

POLICY UPDATE CHANGES

Removed the metformin requirement from all products.

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

Updated Victoza preferred product requirement to a multi-source brand approach and added generic exenatide to follow Byetta criteria.

Policy created as a new policy (New policy).

Conditions Not Covered section updated to explicitly list prediabetes/diabetes prevention and other non‑diabetes indications.

7drug products listed in policy

1 yearinitial approval duration

Requiredprior authorization

Not covered

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Coverage Criteria

FDA‑Approved Indication (Initial Therapy)

Covered when ALL of the following are met

Diagnosis of Type 2 diabetes mellitus is documented

Documentation Required

Age: Patient is 18 years of age or older unless product labeling supports pediatric use

Some agents have pediatric indications (see product labeling)

Prior authorization has been obtained for the requested GLP-1 or GLP-1/GIP agent

Approvals are typically provided for 1 year

Product-specific requirements: Requested product meets any product-specific preferred product or trial requirements listed in the policy tables

Example: Victoza requires trial of the bioequivalent generic unless prescriber documents significant allergy or serious adverse reaction to inactive ingredients

The GLP‑1 receptor agonists and the GLP‑1/GIP agonist addressed in this policy are not covered when used for indications other than treatment of Type 2 diabetes mellitus. Examples of uses that are excluded include treatment for weight loss (patients who are overweight or obese without Type 2 diabetes), management of prediabetes/diabetes prevention, treatment of metabolic syndrome in the absence of Type 2 diabetes, and treatment of Type 1 diabetes mellitus.

GLP‑1 agonists and the GLP‑1/GIP agonist are considered not medically necessary for any use other than treatment of Type 2 diabetes. This includes, but is not limited to, use for weight loss (note that separate GLP‑1 products approved specifically for chronic weight management—e.g., Saxenda, Wegovy, Zepbound—are not covered under this policy unless the product is FDA‑labeled for Type 2 diabetes), prediabetes/diabetes prevention, and metabolic syndrome without Type 2 diabetes. The agents in this policy should not be used concomitantly with one another or with other GLP‑1/GLP‑1‑GIP products.

Initial Therapy

Initial authorization for FDA‑approved indication

Diagnosis and age: Documented diagnosis of Type 2 diabetes mellitus and age meets product labeling (typically >=18 years; some agents have pediatric indications)

Documentation Required

Product-specific: For Victoza (liraglutide): patient has tried the bioequivalent generic liraglutide subcutaneous injection and cannot take it due to a formulation difference in inactive ingredient(s) (e.g., dyes, fillers, preservatives) that, per the prescriber, would result in a significant allergy or serious adverse reaction

See product table for details

Approval duration: Initial approvals are provided for 1 year for the FDA‑approved indication

Continuation / Renewal Criteria

Continuation Therapy

Continuation/renewal

Renewal duration: Approvals are typically provided for 1 year for FDA‑approved indication

Documentation should support ongoing diagnosis of Type 2 diabetes mellitus

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for benefit coverage of the GLP‑1 and GLP‑1/GIP agonists targeted in this policy. Approvals are provided for the duration noted in the policy. Note that Saxenda (liraglutide subcutaneous injection), Wegovy (semaglutide subcutaneous injection), and Zepbound (tirzepatide subcutaneous injection) are not indicated for treatment of diabetes and are not targeted in this policy.

All approvals are provided for the duration noted in the policy.

Step Therapy

Preferred Product Requirement for Victoza

For Victoza (liraglutide subcutaneous injection), coverage requires trial of the bioequivalent generic liraglutide product unless the prescriber documents that inactive ingredient differences (for example, dyes, fillers, preservatives) would cause a significant allergy or serious adverse reaction.

Applies to Individual and Family Plans.
Documentation from the prescriber must specify the formulation difference and clinical rationale.

Coding and Age Indications

Pediatric age indication

Pediatric age indicationLiraglutide, Trulicity, and Bydureon BCise are indicated for patients >= 10 years of age

Typical adult indicationMost GLP‑1 and GLP‑1/GIP agents are indicated as adjuncts to diet and exercise to improve glycemic control in adults with type 2 diabetes

Products called outLiraglutide (Victoza), Trulicity (dulaglutide), Bydureon BCise (exenatide ER) have pediatric labeling (>=10 years)

Step Therapy / Preferred Product Requirements

Step	Requirement
1	Required trial of the bioequivalent generic liraglutide (liraglutide subcutaneous injection) prior to coverage of brand Victoza (liraglutide) unless the prescriber documents that differences in inactive ingredient(s) (for example, dyes, fillers, preservatives) between the brand and the bioequivalent generic would result in a significant allergy or serious adverse reaction.

Definitions

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

DefinitionGLP‑1/GIP agonist — example: tirzepatide (Mounjaro), a dual GLP‑1 and GIP receptor agonist

Class roleActs as an adjunct to diet and exercise to improve glycemic control in type 2 diabetes

Relation to other agentsIncluded with GLP‑1 receptor agonists in this policy's scope of targeted agents

Background

GLP‑1 receptor agonists and the GLP‑1/GIP agonist in this policy are indicated as adjuncts to diet and exercise to improve glycemic control in adults with Type 2 diabetes mellitus. Certain agents also have pediatric indications for patients aged ≥10 years and some agents have additional labeled indications for cardiovascular or renal risk reduction. Clinical guidance supports use of GLP‑1 agents particularly for patients with established atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease and for weight management considerations when obesity is present. Prior authorization is required for these agents and approvals for FDA‑approved indications are typically provided for 1 year.