CurrentCignaPolicy N/A

Diabetes - Ozempic Drug Quantity Management Policy - Per Days

Defines per-days quantity limits for Ozempic (semaglutide subcutaneous injection) across strengths and packaging for Cigna-administered health benefit plans, including retail and home delivery maximums and a statement that the product is covered as medically necessary when criteria are met. No overrides to per-days limits are permitted.

Policy Summary

PayerCigna

PolicyDiabetes - Ozempic Drug Quantity Management Policy - Per Days

Policy CodePolicy N/A

Change TypeQuantity limits / per-days management

Effective Date

Next Review Date

Key ActionPrescribers and pharmacists must ensure dispensed quantities do not exceed the Retail maximum per 28 days or Home Delivery maximum per 84 days for the specific Ozempic strength/form; no overrides to per-days limits are allowed.

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.

10Distinct strength/form retail/home limits listed

3Discontinued packaging variants noted

Coverage Summary

Background: Ozempic (semaglutide) is a glucagon-like peptide-1 (GLP-1) receptor agonist indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus and to reduce the risk of major adverse cardiovascular events in adults with type 2 diabetes mellitus and established cardiovascular disease.

Medically Necessary Coverage

Diabetes - Ozempic Drug Quantity Management Policy - Per Days product(s) is(are) covered as medically necessary when the following criteria is(are) met. Any other exception is considered not medically necessary.

ALL of the following

Requested medication is Ozempic (semaglutide subcutaneous injection) in an approved strength/form
Quantity requested does not exceed the specified Retail or Home Delivery Maximum Quantity per the strength/form (see Drug Quantity Limits)
See Drug Quantity Limits for specific retail (per 28 days) and home delivery (per 84 days) maximums
No overrides to the Per Days quantity limits are permitted

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Retail/Home Delivery Maximum Quantity

Retail Maximum Quantity Per 28 Days - 2 mg/1.5 mL (0.25 & 0.5 mg dose pen) [discontinued]1.5 mL (1 pen)

Home Delivery Maximum Quantity Per 84 Days - 2 mg/1.5 mL (0.25 & 0.5 mg dose pen) [discontinued]4.5 mL (3 pens)

Retail Maximum Quantity Per 28 Days - 2 mg/3 mL (0.25 & 0.5 mg dose pen)3 mL (1 pen)

Home Delivery Maximum Quantity Per 84 Days - 2 mg/3 mL (0.25 & 0.5 mg dose pen)9 mL (3 pens)

Retail Maximum Quantity Per 28 Days - 2 mg/1.5 mL (1 mg dose pen) [discontinued]3 mL (2 pens)

Home Delivery Maximum Quantity Per 84 Days - 2 mg/1.5 mL (1 mg dose pen) [discontinued]9 mL (6 pens)

Retail Maximum Quantity Per 28 Days - 4 mg/3 mL (1 mg dose pen)3 mL (1 pen)

Home Delivery Maximum Quantity Per 84 Days - 4 mg/3 mL (1 mg dose pen)9 mL (3 pens)

Retail Maximum Quantity Per 28 Days - 8 mg/3 mL (2 mg dose pen)3 mL (1 pen)

Home Delivery Maximum Quantity Per 84 Days - 8 mg/3 mL (2 mg dose pen)9 mL (3 pens)

Provider Actions

Documentation Required

Adhere to per-days quantity limits

Prescribers and pharmacists must ensure dispensed quantities do not exceed the Retail maximum per 28 days or Home Delivery maximum per 84 days for the specific Ozempic strength/form; no overrides to per-days limits are allowed.

Retail max per 28 days: see Drug Quantity Limits for specific strength/form
Home Delivery max per 84 days: see Drug Quantity Limits for specific strength/form
No overrides permitted per policy

Background & Definitions

Policy purpose: This Drug Quantity Management program has been developed to promote the safe, effective, and economic use of Ozempic and to set per-days quantity limits for dispensing at retail and home delivery.

Per-days limits: The policy establishes specific Retail and Home Delivery maximum quantities per strength/form (see Drug Quantity Limits) and states that no overrides to the Per Days quantity limits are permitted.

Scope: The policy applies to health benefit plans administered by Cigna companies and defines retail and home delivery maximums for Ozempic across listed strengths and packaging; coverage is limited to situations meeting the policy criteria.

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.