providers-news-2023-pharmacy-glp-1-drugs-11-2023.pdf
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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.
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)
| 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 |
| Wegovy | Excluded when used for weight loss/management |
| Saxenda | Excluded when used for weight loss/management |
What providers must do
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.
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.
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
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
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.
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
Missing required documentation or off‑label indications will lead to denials
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.
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