CurrentCignaPolicy N/A

Diabetes - Liraglutide Drug Quantity Management Policy - Per Days Victoza (liraglutide)

Defines per-days drug quantity limits and dispensing rules for liraglutide (Victoza and authorized generic) for Cigna-administered health benefit plans; affects pharmacy benefit administrators, dispensing pharmacists, and prescribers for members in applicable plans.

Policy Summary

PayerCigna

PolicyDiabetes - Liraglutide Drug Quantity Management Policy - Per Days

Policy CodePolicy N/A

Change TypeAdded / Revised / Removed

Effective Date

Next Review DateOct 30, 2024

Key ActionEnsure dispensed quantity does not exceed specified retail or home delivery per‑days limits; requests over limits will be denied with no overrides.

SourceLink

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 name of the policy was changed to 'Diabetes - Liraglutide Drug Quantity Management Policy - Per Days'.

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 and moved to a separate GLP-1 claim-level policy.

6 mL / 2 pensRetail max / 30 days (2-pack)

18 mL / 6 pensHome delivery max / 90 days (2-pack)

9 mL / 3 pensRetail max / 30 days (3-pack)

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Coverage Criteria

Initial and Ongoing Coverage

Covered when ALL of the following are met

Per-days quantity limits: Dispensed quantity does not exceed the specified retail or home delivery maximums for the 18 mg/3 mL pen (2-pack or 3-pack)Retail: 6 mL/30 days (2-pack) or 9 mL/30 days (3-pack); Home delivery: 18 mL/90 days (2-pack) or 27 mL/90 days (3-pack)

There are no overrides to these per-days quantity limits

Any request that exceeds the Per Days quantity limits for liraglutide (Victoza, authorized generic) is considered not medically necessary. The policy establishes specific dispensing maximums and enforces these limits for the 18 mg/3 mL pen configurations; requests above those per‑day/per‑period quantities will be denied.

Exceptions or overrides to the established per‑days quantity limits are not permitted. The policy explicitly states there are no overrides to the per‑days quantity limits and that no overrides are recommended; therefore any request seeking an exception will be considered not medically necessary and denied.

Coding and Product

Covered NDC/Strength/FormNDCCovered

18 mg/3 mL

Victoza (liraglutide) prefilled pen strength/form (6 mg/mL)

Maximum dispensing volumes

Retail — 2-pack6 mL per 30 days (2 pens)

Retail — 3-pack9 mL per 30 days (3 pens)

Home delivery — 2-pack18 mL per 90 days (6 pens)

Home delivery — 3-pack27 mL per 90 days (9 pens)

Provider Actions & Billing Rules

Billing Rule

Quantity limits enforced

Victoza (liraglutide) quantity limits are enforced as shown below. Retail and home delivery maximums apply per the listed timeframes; there are no overrides to these Per Days limits.

Victoza (liraglutide SC injection) 18 mg/3 mL pen (2-pack): Retail maximum per 30 days = 6 mL (2 pens); Home Delivery maximum per 90 days = 18 mL (6 pens).
Victoza (liraglutide SC injection) 18 mg/3 mL pen (3-pack): Retail maximum per 30 days = 9 mL (3 pens); Home Delivery maximum per 90 days = 27 mL (9 pens).

Step Therapy

Step/claim-level rule relocation

Claim-level GLP‑1 agonist dispensing rules (for example, the previous rule allowing one GLP‑1 or GLP‑1/GIP agonist claim every 21 days) have been removed from this document. For information on claim-level GLP‑1 dispensing limits and associated overrides, refer to the separate 'Diabetes - Glucagon-Like Peptide-1 Agonists Drug Quantity Management Policy - Claim Per Days' document.

Definitions

SC — Definition

AbbreviationSC = Subcutaneous

RouteSubcutaneous injection for liraglutide (Victoza)

Administration contextUsed for daily dosing as described in prescribing information

Initial Therapy Criteria

Initial Therapy

Initial dosing per prescribing information

Initial dosing: Start at 0.6 mg subcutaneous (SC) once daily for 1 week to mitigate gastrointestinal symptoms, then increase to 1.2 mg SC once daily. If additional glycemic control is needed, may increase to 1.8 mg SC once daily after at least 1 week at 1.2 mg.See prescribing information

Prescribing information referenced: Victoza PI (July 2023)

Continuation / Titration Criteria

Continuation/Titration

Dosing and titration for continued therapy

Titration schedule: Adults: start 0.6 mg SC once daily for 1 week then increase to 1.2 mg SC once daily; may increase to 1.8 mg SC once daily after at least 1 week at 1.2 mg. Pediatrics (≥10 years): start 0.6 mg SC once daily and increase by 0.6 mg increments as needed up to 1.8 mg SC once daily.Dose increments per prescribing information

If >3 days missed in pediatric patients, reinitiate at 0.6 mg once daily per prescribing information

Step Therapy / Claim-Level Rules

Step	Description
1	Claim-level rule limiting one GLP-1 agonist or GLP-1/GIP agonist claim every 21 days at retail or home delivery was removed from this policy and relocated to the 'Diabetes - Glucagon-Like Peptide-1 Agonists Drug Quantity Management Policy - Claim Per Days'.

Quantity Limits (Per-Days)

Victoza 18 mg/3 mL pen (2-pack) — Retail

ProductVictoza (liraglutide) 18 mg/3 mL pen (2-pack)

Retail limit6 mL per 30 days (2 pens)

Equivalent pens2 pens (6 mL total)

Victoza 18 mg/3 mL pen (2-pack) — Home delivery

ProductVictoza (liraglutide) 18 mg/3 mL pen (2-pack)

Home delivery limit18 mL per 90 days (6 pens)

Equivalent pens6 pens (18 mL total)

Background

Liraglutide (Victoza) is a glucagon‑like peptide‑1 (GLP‑1) receptor agonist indicated as an adjunct to diet and exercise to improve glycemic control in adults and pediatric patients aged ≥10 years with type 2 diabetes mellitus, and to reduce major adverse cardiovascular events in adults with type 2 diabetes and established cardiovascular disease. Standard dosing begins at 0.6 mg administered subcutaneously (SC) once daily for 1 week to mitigate gastrointestinal symptoms, with subsequent titration to 1.2 mg and up to 1.8 mg daily per the prescribing information; pediatric dosing follows similar 0.6 mg initiation and titration up to 1.8 mg as needed.