CurrentCignaPolicy N/A

Diabetes - Trulicity Drug Quantity Management Policy - Per Days

Cigna Drug Quantity Management policy governing maximum dispensed quantities and refill intervals for all strengths of Trulicity (dulaglutide) for covered health benefit plans administered by Cigna companies. It defines retail and home delivery maximum quantities per defined day periods and states that product is covered as medically necessary when criteria are met.

Policy Summary

PayerCigna

PolicyDiabetes - Trulicity Drug Quantity Management Policy - Per Days

Policy CodePolicy N/A

Change TypeAdded and Removed quantity limits

Effective Date

Next Review Date

Key ActionDo not dispense or bill for more than retail: 2 mL (4 pens) per 28 days or home delivery: 6 mL (12 pens) per 84 days; there are no overrides to the Per Days quantity limits outlined in this policy.

POLICY UPDATE CHANGES

New policy created to add additional quantity limits to approve ONE claim collectively for ONE GLP-1 agonist or GLP-1/GIP agonist every 21 days at retail or home delivery.

The quantity limit of ONE claim of ONE GLP-1 agonist or GLP-1/GIP agonist to be dispensed every 21 days at retail or home delivery was removed from this policy.

4 pensRetail max per 28 days

12 pensHome delivery max per 84 days

allApplies to strengths

Coverage Summary

Cigna Drug Quantity Management policy governing maximum dispensed quantities and refill intervals for all strengths of Trulicity (dulaglutide) for covered health benefit plans administered by Cigna companies. Product is considered covered with criteria and is covered as medically necessary when the specified quantity limit criteria are met — specifically, coverage requires that the medication is Trulicity (any strength) and the dispensed quantity does not exceed the defined maximum per period for the strength and channel.

All strengths of Trulicity (dulaglutide) apply. The policy defines maximum dispensing limits by channel: Retail: 2 mL (4 pens) per 28 days and Home delivery: 6 mL (12 pens) per 84 days.

Quantity limits

Retail maximum quantity per 28 days (all strengths)2 mL (4 pens) per 28 days

Home delivery maximum quantity per 84 days (all strengths)6 mL (12 pens) per 84 days

Applies to strengthsall strengths

Initial / Quantity Criteria

Medical necessity for Trulicity under Drug Quantity Management

Trulicity (all strengths) is covered as medically necessary when the following quantity limit criteria are met. Any other exception is considered not medically necessary.

ALL of the following

Medication is Trulicity (dulaglutide) (any strength)
Quantity limit: Dispensed quantity does not exceed the defined maximum quantity per period for the strength and channel (retail or home delivery)Retail: 2 mL (4 pens) per 28 days; Home delivery: 6 mL (12 pens) per 84 days
There are no overrides to the Per Days quantity limits outlined in this policy.

ref": "b1_0

title": "Medical necessity for Trulicity under Drug Quantity Management

Operational note: Any other exception is considered not medically necessary. The policy specifies that there are no overrides to the Per Days quantity limits. The defined maximum quantities differ by channel and period: Retail maximum — 2 mL (4 pens) per 28 days and Home delivery maximum — 6 mL (12 pens) per 84 days.

Provider Actions & Billing Rules

Billing Rule

Adhere to quantity limits

Do not dispense or bill for more than retail: 2 mL (4 pens) per 28 days or home delivery: 6 mL (12 pens) per 84 days; there are no overrides to the Per Days quantity limits outlined in this policy.

Retail: 4 pens per 28 days
Home delivery: 12 pens per 84 days

Operational implications: systems and staff must enforce the per-period quantity limits for each channel (retail per 28 days and home delivery per 84 days). There are no overrides to these Per Days limits, and recent changes referenced removal of the separate Claim Per Days limit directing users to the 'Claim Per Days' document for additional information.

Background and Clinical Evidence

Background: Trulicity is a GLP-1 receptor agonist indicated as an adjunct to diet and exercise to improve glycemic control in adults and pediatric patients ≥10 years with type 2 diabetes mellitus, and to reduce the risk of major adverse cardiovascular events in adults with type 2 diabetes who have established cardiovascular disease or multiple cardiovascular risk factors. Trulicity is supplied as single-dose pens in cartons of four pens and is available in 0.75 mg, 1.5 mg, 3 mg, and 4.5 mg strengths.

Prescribing information: Trulicity subcutaneous injection prescribing information, Lilly; November 2022

Definitions

SCSubcutaneous

QWOnce weekly

Revision History

07/17/2024added

New policy created to add additional quantity limits to approve ONE claim collectively for ONE GLP-1 agonist or GLP-1/GIP agonist every 21 days at retail or home delivery. New clinical overrides applied to these limits; existing 'Per Days' quantity limits were not changed and no overrides applied.

10/30/2024removedLatest

The quantity limit of ONE claim of ONE GLP-1 agonist or GLP-1/GIP agonist to be dispensed every 21 days at retail or home delivery was removed from this policy; refer to the 'Diabetes - Glucagon-Like Peptide-1 Agonists Drug Quantity Management Policy - Claim Per Days' document for additional information.