CurrentCignaPolicy N/A

Diabetes - Exenatide Products Drug Quantity Management Policy - Per Days

Defines per-days retail and home delivery maximum quantity limits for exenatide products (Byetta 5 mcg & 10 mcg pens; Bydureon BCise 2 mg auto-injector) for Cigna-administered health benefit plans and states that these products are covered when criteria are met. No overrides to the per-days limits are permitted.

Policy Summary

PayerCigna

PolicyDiabetes - Exenatide Products Drug Quantity Management Policy - Per Days

Policy CodePolicy N/A

Change TypeRemovals of prior quantity limits

Effective Date

Next Review Date

Key ActionReport and dispense no more than the specified retail and home delivery maximum quantities for each product and timeframe; claims exceeding these per-days limits have no overrides and are considered not medically necessary.

SourceLink

POLICY UPDATE CHANGES

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

Quantity limits for Bydureon 2 mg/0.65 mL pen were removed from the policy.

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

3Products listed

6Per-days thresholds

Policy summary

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This Drug Quantity Management program is designed to promote the safe, effective, and economic use of exenatide products (GLP-1 agonists Byetta and Bydureon BCise) for Cigna-administered health benefit plans. It applies to plans administered by Cigna companies and is intended to guide dispensing limits and coverage determinations for these products.

Products (Byetta and Bydureon BCise) are covered as medically necessary when the per-days quantity limits are met; any other exception is considered not medically necessary. Specific per-days retail and home delivery maximum quantities are defined for each product and must be followed. The terms of a customer’s applicable benefit plan document always supersede this policy, and there are no overrides to the Per Days quantity limits outlined in this policy. Refer to the plan documents for any controlling differences.

Billing and documentation requirements

Billing Rule

Adhere to per-days quantity limits

Report and dispense no more than the specified retail and home delivery maximum quantities for each product and timeframe (see policy per‑days limits). Claims exceeding these per‑days limits have no overrides and are considered not medically necessary.

Documentation Required

Coverage requires adherence to policy limits

Ensure documentation supports that the dispensed quantity conforms to the per‑days limits defined in this policy; exceptions or overrides to these limits are not permitted and claims outside these limits are considered not medically necessary.

Background and evidence

This program promotes the safe, effective, and economic use of exenatide products (Byetta and Bydureon BCise) and applies to dispensing limits for Cigna-administered benefit plans. The policy defines per-days retail and home delivery maximum quantities for these products and notes that plan documents supersede the coverage policy; no overrides to the per-days limits are permitted.

Evidence

Byetta prescribing informationAstraZeneca; December 2022

Bydureon BCise prescribing informationAstraZeneca; March 2024

Policy changes and history

07/17/2024created

New policy created to add additional quantity limits to approve ONE claim collectively for ONE GLP-1 or GLP-1/GIP agonist every 21 days at retail or home delivery; Bydureon 2 mg/0.65 mL pen quantity limits were removed from the policy (Review Date = 07/17/2024).

10/30/2024revisedLatest

Early annual revision removed the quantity limit of ONE claim of ONE GLP-1 or GLP-1/GIP agonist to be dispensed every 21 days at retail or home delivery; refers to 'Diabetes - Glucagon-Like Peptide-1 Agonists Drug Quantity Management Policy - Claim Per Days' for details.