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.
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.
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.
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