ModifiedFlorida BluePolicy N/A

providers-news-2023-pharmacy-glp-1-drugs-11-2023.pdf

Provider bulletin from Florida Blue describing pharmacy coverage and prior authorization requirements for the GLP-1 drug class for commercial and Medicare plans, limiting coverage to FDA‑approved indications for type 2 diabetes and excluding use for weight loss/management.

Policy Summary

PayerFlorida Blue

Policyproviders-news-2023-pharmacy-glp-1-drugs-11-2023.pdf

Policy CodePolicy N/A

Change TypeCoverage & prior authorization criteria revised

Effective Date

Next Review Date

Key ActionProviders must include clinical documentation of a type 2 diabetes diagnosis and document prior trial/failure of metformin/metformin combos or insulin with GLP‑1 prior authorization requests; requests lacking this documentation will be denied.

POLICY UPDATE CHANGES

Commercial GLP‑1 prior authorization criteria were updated to require clinical documentation of type 2 diabetes diagnosis and documentation of prior trial/failure of metformin/metformin combinations or insulin.

Florida Blue clarified that GLP‑1 coverage is limited to FDA‑approved indications for type 2 diabetes and that medications for weight loss/management are excluded.

5Preferred GLP-1 agents listed

What changed — quick summary

Florida Blue updated provider communications clarifying that GLP-1 class coverage is limited to FDA‑approved indications for type 2 diabetes; prior authorization requests for off‑label uses (including weight loss/management) will not be approved.

Prime Therapeutics is Florida Blue's pharmacy benefits manager and will handle prior authorization requests; the updated criteria increase documentation requirements (clinical documentation of a type 2 diabetes diagnosis and prior trial/failure of metformin/metformin combinations or insulin), creating additional administrative burden and resulting in denials if required documentation is not provided.

Coverage criteria and denial conditions

Coverage criteria for GLP-1 drugs (commercial plans)

Covered when ALL of the following are met:

ALL of the following

FDA‑approved indication: Indication is an FDA‑approved indication related to treatment of type 2 diabetes (documented in clinical record).
Documented diagnosis: Provider submits clinical documentation of a type 2 diabetes diagnosis with the prior authorization request.
Prior therapy trial/failure: Documentation shows patient has tried and failed metformin, other metformin combination drugs, or insulin to demonstrate medical necessity for GLP‑1 approval.

Not covered / will be denied

Authorization requests will be denied when ANY of the following apply:

ANY of the following

Off‑label/not FDA‑approved indication: Indication is off‑label or not an FDA‑approved indication for type 2 diabetes (including weight loss/management).
Missing diagnosis documentation: Provider fails to provide clinical documentation of a type 2 diabetes diagnosis.
Missing prior therapy documentation: Provider fails to document prior trial and failure of metformin, metformin combination drugs, or insulin when required by prior authorization criteria.

Covered and excluded GLP‑1 drugs (examples)

Preferred GLP-1 drugs covered for type 2 diabetes (commercial plans)mixedCovered

Mounjaro	Preferred GLP-1 product listed by Florida Blue for type 2 diabetes
Rybelsus	Preferred GLP-1 product listed by Florida Blue for type 2 diabetes
Ozempic	Preferred GLP-1 product listed by Florida Blue for type 2 diabetes
Trulicity	Preferred GLP-1 product listed by Florida Blue for type 2 diabetes
Victoza	Preferred GLP-1 product listed by Florida Blue for type 2 diabetes

Examples of excluded medications for weight loss/managementmixedNot Covered

Wegovy	Excluded when used for weight loss/management
Saxenda	Excluded when used for weight loss/management

What providers must do

Prior Authorization

Submit clinical documentation of type 2 diabetes

Providers must include clinical documentation of a type 2 diabetes diagnosis with GLP‑1 prior authorization requests; requests lacking this documentation will be denied.

Prior Authorization

Document prior therapy trial/failure

Providers must document that the patient has tried and failed metformin, metformin combination drugs, or insulin when requesting GLP‑1 coverage to demonstrate medical necessity; failure to do so will result in denial.

Denial Risk

Do not submit requests for weight loss/management

Requests for GLP‑1 medications for weight loss/management (including Wegovy, Saxenda, or similar) will be denied and should not be submitted to Prime Therapeutics; patients must pay out-of-pocket if pursued.

Wegovy
Saxenda

Documentation Required

Reference prior authorization questions

Providers should use the GLP‑1 prior authorization criteria questions available at myPrime.com and submit required documentation through Prime Therapeutics/CoverMyMeds per Florida Blue guidance.

Submit prior authorization requests via Prime Therapeutics/CoverMyMeds
Reference GLP‑1 prior authorization questions at myPrime.com

Definitions and scope notes

GLP-1: Glucagon-like Peptide 1 drug class.

Applies to Florida Blue commercial and Medicare pharmacy plans; coverage is limited to FDA‑approved type 2 diabetes indications and explicitly excludes medications used for weight loss/management (requests for weight‑loss indications should not be submitted to Prime Therapeutics and will be denied).

Change summary & material impact

revised

Commercial GLP-1 prior authorization criteria were updated to require clinical documentation of a type 2 diabetes diagnosis and documentation that the patient has tried and failed metformin, metformin combination drugs, or insulin; requests lacking this documentation will be denied.

Effective Jan 1, 2024clarifiedLatest

Florida Blue clarified GLP-1 coverage is limited to FDA‑approved indications for treatment of type 2 diabetes; medications for weight loss/management (e.g., Wegovy, Saxenda) are excluded and some commercial and Medicare members will no longer be covered starting January 1, 2024 if they do not meet policy guidelines.

This is a material change that increases documentation requirements and will result in denials if not met; providers must submit clinical documentation of a type 2 diabetes diagnosis and evidence of prior trial/failure of metformin, metformin combination drugs, or insulin. Additionally, some commercial and Medicare members will no longer be covered for GLP‑1 drugs starting January 1, 2024 if they do not meet the updated policy guidelines, and weight‑loss/management uses (e.g., Wegovy, Saxenda) are excluded from coverage.

Effective dates and immediate actions

Effective date and actions

Effective dateJan 1, 2024

Key actionSubmit required clinical documentation with PA: include documentation of type 2 diabetes diagnosis and prior trial/failure of metformin/metformin combinations or insulin

Key actionDo not submit requests for weight-loss/management indications (eg, Wegovy, Saxenda); these will be denied and must be paid OOP

Key actionUse Prime Therapeutics and CoverMyMeds to submit PA requests and follow GLP-1 prior authorization questions at myPrime.com