CurrentColorado Rocky Mountain Health PlansPolicy N/A

GLP-1 Receptor Agonists and Combination Products Prior Authorization Coverage Criteria

Requirements and checklist for initial and continuation prior authorization requests for GLP-1 receptor agonists and combination products for members (Type 2 Diabetes focus), directed to prescribing providers requesting coverage.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyGLP-1 Receptor Agonists and Combination Products Prior Authorization Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete the GLP-1 receptor agonist prior authorization form with diagnosis, prior metformin trial or documented contraindication, ASCVD/CKD status, trials of preferred products for non-preferred agents, and prescriber signature/NPI.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Initial & continuationtypes of requests addressed

Prescriber signature + NPIauthorization form fields

Metformin trial requiredmetformin trial requirement

>=2 preferred failednon-preferred product requirement

Clinical improvement requiredcontinuation documentation

Coverage Criteria for GLP-1 Receptor Agonists

inv-01: Initial Therapy

Covered when ALL of the following are met:

Initial GLP-1 authorization: 1) Beneficiary has a diagnosis of Type 2 Diabetes; 2) Beneficiary has had a trial and failure or insufficient response to metformin-containing products OR has a documented contraindication or adverse event to metformin (must list); 3) Documented ASCVD status (established ASCVD present or absent); 4) Documented chronic kidney disease (present or absent); 5) For non-preferred products, beneficiary has tried and failed or had an insufficient response to at least two preferred products OR there is a documented clinical reason preferred products cannot be tried; plus prescriber signature (mandatory).

Derived from the GLP-1 receptor agonist initial request checklist

inv-02: Continuation Therapy

Covered when ALL of the following are met:

Continuation GLP-1 authorization: 1) Documentation beneficiary has improved while on this medication (attach medical documentation); 2) Individual clinical goals set by the provider are being met; 3) Beneficiary continues to make adequate progress toward treatment goals; plus prescriber signature (mandatory).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyGLP-1 Receptor Agonists and Combination Products Prior Authorization Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

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The form does not present a separate "not medically necessary" list; however, it makes clear that required clinical documentation is necessary for approval. In practice, a request would effectively be not approved if the provider fails to supply the necessary items shown on the form — for example, confirmation of a Type 2 Diabetes diagnosis, documentation of a trial and failure or contraindication to metformin, completion of the trial requirements for non‑preferred products, or clinical documentation showing improvement for continuation requests.

Providers should attach medical records demonstrating the items requested on the form (diagnosis, prior therapy trials or contraindications, ASCVD/CKD status, and for continuations, documentation of improvement and progress toward individualized goals) because omission of these items may result in denial.

Provider Requirements and Submission Checklist

Prior Authorization

Prior authorization form completion — Required fields and signature

Complete and submit the GLP-1 receptor agonist prior authorization request form. The form must be signed by the prescriber and include the prescriber NPI, requester contact information, beneficiary identifiers (name, ID, DOB, gender), drug name, strength, quantity per 30 days, and requested length of therapy.

Prescriber signature and date required
Prescriber NPI required
Requester name and phone number required
Beneficiary name, ID, DOB, and gender required
Drug name, strength, quantity per 30 days, and length of therapy must be provided

Step Therapy

Preferred product trial requirement

For non-preferred GLP-1 products, the request must document that the beneficiary has tried and had an inadequate response or intolerance to at least two preferred GLP-1 products, or provide a clinical reason why preferred products cannot be used.

Document names and dates of at least two preferred product trials and reasons for failure/insufficient response or intolerance
If preferred products cannot be tried, provide clinical justification

Documentation Required

Required documentation — Attach medical records

Attach supporting medical documentation demonstrating the beneficiary's diagnosis, prior therapy trials or contraindications (including metformin trial or documented contraindication/adverse event), and clinical response or intolerance to prior treatments.

Documented diagnosis of Type 2 Diabetes required for initial requests
Evidence of metformin trial and failure OR documented contraindication/adverse event to metformin
For continuation requests, attach documentation of clinical improvement and progress toward individualized goals

Denial Risk

Missing required clinical items — Denial risk

Missing required clinical items may result in denial. Failure to document a Type 2 Diabetes diagnosis, prior metformin trial or contraindication, prescriber signature/NPI, or required prior trials for non-preferred products are common reasons for denial.

Omission of prescriber signature or NPI may lead to denial
Failure to document metformin trial or contraindication may lead to denial
Insufficient documentation of trials for non-preferred products may result in denial

Background

This request form is focused on authorization of GLP‑1 receptor agonists for persons with Type 2 Diabetes. For initial requests the form requires confirmation of the diagnosis, documentation of a trial and failure or insufficient response to metformin (or a listed contraindication/adverse event), and recording of ASCVD and chronic kidney disease status. For non‑preferred GLP‑1 products the form additionally asks whether the beneficiary has tried and failed (or had an insufficient response to) at least two preferred products or whether there is a clinical reason preferred products cannot be used. For continuation requests the form requires documentation that the beneficiary has improved while on the medication, that individualized clinical goals are being met, and that the beneficiary is making adequate progress toward treatment goals; medical documentation must be attached.

Definitions

Continuation request

DefinitionContinuation request: a request to continue therapy where the provider must document improvement while on the medication, that individual clinical goals set by the provider are being met, and that the beneficiary continues to make adequate progress toward treatment goals.

Required documentationAttach medical documentation showing clinical improvement, attainment of individualized goals, and ongoing progress toward treatment goals for the continuation request.

Prescriber attestationPrescriber signature is mandatory on the form certifying accuracy and completeness of the information provided.

Clinical items to confirmFor continuation requests confirm: improvement on medication; individual clinical goals are being met; beneficiary is making adequate progress toward goals.

Form fields relevant to continuationInclude beneficiary identifiers (name, ID, DOB, gender), drug name/strength/quantity per 30 days, and requested length of therapy.