CurrentGeorgia Department of Community HealthPolicy N/A

Georgia Medicaid Fee‑for‑Service Antidiabetic Agents PA Summary

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This document summarizes prior authorization requirements and coverage criteria for antidiabetic medications under Georgia Medicaid Fee‑for‑Service, describing preferred and non‑preferred products and specific approval conditions for various agents.

Policy Summary

PayerGeorgia Department of Community Health

PolicyGeorgia Medicaid Fee‑for‑Service Antidiabetic Agents PA Summary

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and include diagnosis, age, HbA1c (when applicable), and supporting documentation or a written letter of medical necessity for non‑preferred combination products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipledrug classes

7%HbA1c threshold

18+typical adult age

manyLOMN required

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CurrentGeorgia Department of Community HealthPolicy N/A

Georgia Medicaid Fee‑for‑Service Antidiabetic Agents PA Summary

Customize your policy alerts

Sign up for all Georgia Department of Community Health policy alerts

Know when Georgia Department of Community Health releases new policies or updates existing guidance.

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Policy Summary

PayerGeorgia Department of Community Health

PolicyGeorgia Medicaid Fee‑for‑Service Antidiabetic Agents PA Summary

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipledrug classes

7%HbA1c threshold

18+typical adult age

manyLOMN required

Agent-specific Coverage Criteria

Alogliptin and combinations

Alogliptin products

Alogliptin (and combos): Member is >= 18 years with a diagnosis of type 2 diabetes mellitus AND HbA1c >= 7% AND has experienced inadequate response, allergy, contraindication, drug-drug interaction, or intolerable side effects to at least 2 preferred DPP-4 inhibitors.HbA1c >= 7%

Applies to alogliptin generic, alogliptin/metformin generic, alogliptin/pioglitazone generic.

Brynovin

Brynovin (sitagliptin oral solution)

Brynovin: Member is >= 18 years with a diagnosis of type 2 diabetes mellitus AND is unable to swallow solid oral dosage formulations.

Formulation-based approval.

LOMN-required combination products

Combination non-preferred products requiring letter of medical necessity

LOMN requirement: Prescriber must submit a written letter of medical necessity stating why the separate preferred component products are not appropriate for the member.

Applies to Janumet XR, metformin ER osmotic generic, Invokamet/Invokamet XR, Segluromet, Steglujan, Synjardy/Synjardy XR, Trijardy XR, pioglitazone/glimepiride generic, pioglitazone/metformin generic and other listed combination products.

Inpefa

Inpefa (sotagliflozin)

Inpefa: Member is >= 18 years with a diagnosis of heart failure or type 2 diabetes mellitus, chronic kidney disease and other cardiovascular risk AND has experienced inadequate response, allergy, contraindication, drug-drug interaction, or intolerable side effects to the preferred SGLT2 inhibitors dapagliflozin (Farxiga) and empagliflozin (Jardiance).

Step through preferred SGLT2s required.

Invokana

Invokana (canagliflozin)

Invokana approvals: (1) Member >= 10 years with type 2 diabetes mellitus AND HbA1c >= 7% AND inadequate response/intolerance/contraindication to metformin, thiazolidinedione or sulfonylurea, as well as dapagliflozin (Farxiga) or Xigduo XR and Jardiance; OR (2) Member >= 18 years with type 2 diabetes AND HbA1c >= 7% AND established cardiovascular disease AND inadequate response/intolerance/contraindication to dapagliflozin (Farxiga) or Xigduo XR and Jardiance; OR (3) Member >= 18 years with type 2 diabetes AND HbA1c >= 7% AND diabetic nephropathy with albuminuria AND inadequate response/intolerance/contraindication to dapagliflozin (Farxiga) or Xigduo XR and Jardiance.HbA1c >= 7% where specified

Three distinct approval pathways preserved as OR logic.

Steglatro

Steglatro (ertugliflozin)

Steglatro: Member >= 18 years with a diagnosis of type 2 diabetes mellitus AND HbA1c >= 7% AND has experienced inadequate response, allergy, contraindication, drug-drug interaction, or intolerable side effects with metformin, thiazolidinedione or sulfonylurea, as well as dapagliflozin (Farxiga) or Xigduo XR and Jardiance.HbA1c >= 7%

Step through multiple agents required.

Cycloset

Cycloset (bromocriptine)

Cycloset: Member >= 18 years with a diagnosis of type 2 diabetes mellitus AND HbA1c >= 7% AND has experienced inadequate response, allergy, contraindication, drug-drug interaction, or intolerable side effects with metformin AND with at least 3 of the following classes: sulfonylurea, thiazolidinedione, DPP-4 inhibitor, and SGLT2 inhibitor.HbA1c >= 7%

Requires failure/intolerance to metformin plus three other classes.

Cycloset - Initial Approval Criteria

Cycloset — Covered when ALL of the following are met

Cycloset general criteria: Member is ≥18 years old; diagnosis of type 2 diabetes mellitus; HbA1c ≥ 7%; documented inadequate response, allergy, contraindication, drug-drug interaction, or intolerable side effects to metformin; and have experienced inadequate response, allergy, contraindication, drug-drug interaction, or intolerable side effects with three of the following classes: sulfonylurea, thiazolidinedione, DPP-4 inhibitor, and SGLT2 inhibitor.HbA1c >= 7%

All listed medication classes count toward the 3 required failures.

Liraglutide / Victoza - Glycemic and CVD indications

Liraglutide (NDC-limited) and Victoza — Covered when ALL of the following are met

Liraglutide glycemic control: Member is ≥10 years old; diagnosis of type 2 diabetes mellitus; HbA1c ≥ 7%; medication is being used to improve glycemic control.HbA1c >= 7%

NDC restriction: generic liraglutide approvable only for specific NDCs (00480-3667-##).

Liraglutide CVD risk reduction: Member is ≥18 years old; diagnosis of type 2 diabetes mellitus; HbA1c ≥ 7%; medication is being used to reduce risk of major adverse cardiovascular events (MACE) in those with established cardiovascular disease.HbA1c >= 7%

Separate CVD indication requires age ≥18.

Mounjaro - Initial Approval Criteria

Mounjaro — Covered when ALL of the following are met

Mounjaro glycemic control: Member is ≥10 years old; diagnosis of type 2 diabetes mellitus; HbA1c ≥ 7%; medication is being used to improve glycemic control.HbA1c >= 7%

Ozempic - Glycemic, Renal, and CVD indications

Ozempic — Covered when ANY of the following agent-specific indications are met (each has its own criteria all of which include HbA1c ≥ 7% and age ≥18)

Ozempic glycemic control: Member is ≥18 years old; diagnosis of type 2 diabetes mellitus; HbA1c ≥ 7%; medication used to improve glycemic control.HbA1c >= 7%

Ozempic renal outcomes: Member is ≥18 years old; diagnosis of type 2 diabetes mellitus; HbA1c ≥ 7%; medication used to reduce risk of sustained eGFR decline, ESRD and cardiovascular death in chronic kidney disease.HbA1c >= 7%

CKD-related indication.

Ozempic CVD indication: Member is ≥18 years old; diagnosis of type 2 diabetes mellitus; HbA1c ≥ 7%; medication used to reduce risk of MACE in patients with established cardiovascular disease.HbA1c >= 7%

Rybelsus - Glycemic and CVD criteria with prior therapy requirements

Rybelsus — Covered when ALL of the following are met

Rybelsus glycemic control with prior failures: Member is ≥18 years old; diagnosis of type 2 diabetes mellitus; HbA1c ≥ 7%; medication used to improve glycemic control; AND member has experienced inadequate response, allergy, contraindication, drug-drug interaction, or intolerable side effects with dapagliflozin (Farxiga), Xigduo XR or Jardiance AND with a GLP-1 agent (Victoza/liraglutide, Mounjaro or Ozempic).HbA1c >= 7%

Also approvable for CVD MACE reduction with the same prior-therapy requirements.

Soliqua - Combination therapy failure

Soliqua — Covered when ALL of the following are met

Soliqua criteria: Member is ≥18 years old; diagnosis of type 2 diabetes mellitus; HbA1c ≥ 7%; failed to achieve glycemic targets with combination therapy of Lantus and Victoza or liraglutide OR has allergies, contraindications, drug-drug interactions or intolerable side effects to Lantus and Victoza or liraglutide.HbA1c >= 7%

Combination therapy failure or intolerance required.

Trulicity - Age-stratified glycemic and CVD criteria

Trulicity — Covered when ANY of the following are met

Trulicity pediatric/adolescent glycemic control: Member is 10 to 17 years old; diagnosis of type 2 diabetes mellitus; HbA1c ≥ 7%; medication used to improve glycemic control AND member has experienced inadequate response, allergy, contraindication, drug-drug interaction, or intolerable side effects with Victoza or liraglutide and Mounjaro.HbA1c >= 7%

Pediatric pathway requires prior issues with specific agents.

Trulicity adult glycemic control: Member is ≥18 years old; diagnosis of type 2 diabetes mellitus; HbA1c ≥ 7%; medication used to improve glycemic control AND member has experienced inadequate response, allergy, contraindication, drug-drug interaction, or intolerable side effects with Victoza or liraglutide, Mounjaro and Ozempic.HbA1c >= 7%

Adult pathway requires multiple prior-agent issues.

Trulicity CVD indication:

Xultophy - Stabilization or combination failure

Xultophy — Covered when ANY of the following are met

Xultophy stabilized combination: Member has been stabilized on combination therapy with the individual agents Tresiba and Victoza or liraglutide.

Stability on component agents qualifies.

Xultophy glycemic failure: Member is ≥18 years old; diagnosis of type 2 diabetes mellitus; HbA1c ≥ 7%; failed to achieve glycemic targets with combination therapy of Lantus and Victoza or liraglutide OR has allergies, contraindications, drug-drug interactions or intolerable side effects to Lantus and Victoza or liraglutide.HbA1c >= 7%

Alternative pathway similar to Soliqua.

Miglitol - Prior-agent failure requirement

Miglitol — Covered when ALL of the following are met

Miglitol criteria: Member has experienced inadequate response, allergy, contraindication, drug-drug interaction, or intolerable side effects to at least 2 preferred oral antidiabetic agents, one of which must be acarbose.

No specific HbA1c or age stated.

Pioglitazone/Metformin generic - Medical necessity requirement

Pioglitazone/Metformin Generic — Covered when ALL of the following are met

Pioglitazone/Metformin NMO requirement: Prescriber must submit a written letter of medical necessity stating why the separate preferred products (generic pioglitazone and generic metformin) are not appropriate for the member.

Approval contingent on medical necessity letter.

This policy distinguishes between preferred and non‑preferred antidiabetic products across multiple drug classes. Preferred agents (examples include sitagliptin/Januvia, dapagliflozin where not NDC‑restricted, empagliflozin/Jardiance, metformin generics and common generics for sulfonylureas and TZDs) are listed separately from non‑preferred products (for example, alogliptin and its combinations, certain combination ER metformin products, some fixed‑dose SGLT2 combinations, pioglitazone/metformin generic, and selected branded GLP‑1/tablet products). The presence of a product on the non‑preferred list does not state an absolute exclusion but indicates the product is subject to prior authorization or additional documentation as specified elsewhere in this summary.

Exceptions to the coverage conditions are handled through the prior authorization process; providers must follow the OptumRx PA workflow to request coverage exceptions. The PA process may be initiated by calling OptumRx at 1‑866‑525‑5827 and any exception request should include relevant clinical documentation.

When requesting exceptions or prior authorization for non‑preferred or combination products, prescribers should be prepared to submit supporting documentation such as diagnosis, member age, and pertinent laboratory values (e.g., HbA1c where applicable), as well as a written letter of medical necessity when required to justify use of a non‑preferred combination instead of the separate preferred component products.

Age, HbA1c and Formulation Definitions

inv-20: HbA1c

Common HbA1c thresholdHbA1c ≥ 7% is required for coverage consideration for many agents (e.g., alogliptin, Invokana, Steglatro, Cycloset, Rybelsus)

Alogliptin-specificAlogliptin products approvable for members ≥ 18 years with type 2 diabetes and HbA1c ≥ 7% after inadequate response/intolerance to ≥2 preferred DPP‑4 inhibitors

GLP‑1 agentsMany GLP‑1 approvals (e.g., Victoza, Ozempic, Trulicity, Rybelsus) require HbA1c ≥ 7% as part of glycemic- or CVD-related indications

inv-21: Age (Invokana pediatric approval)

Invokana pediatric pathwayApprovable for members 10 years of age or older with type 2 diabetes mellitus when HbA1c ≥ 7% and required prior therapy failures/intolerance to metformin, TZD or sulfonylurea and to dapagliflozin/Xigduo XR and Jardiance

Age threshold value

Prior Authorization, Documentation, and Step Therapy

Prior Authorization

Prior authorization required for listed non-preferred antidiabetic agents

Prior authorization is required for the specified non-preferred antidiabetic agents; approvals are contingent on meeting agent-specific clinical criteria such as age, diagnosis of type 2 diabetes mellitus, HbA1c thresholds, and prior trials/intolerance to preferred agents.

Prior Authorization

Agent-specific clinical criteria must be met for PA approval

Authorizations will only be approved when the agent-specific clinical criteria in the policy are met (for example: minimum age requirements, diagnosis of type 2 diabetes mellitus, HbA1c ≥ 7% where specified, and any agent-specific prior therapy failures or intolerances).

Step Therapy

Step therapy / prior trial requirements apply

Clinical Context

Type 2 diabetes mellitus is managed with multiple oral and injectable classes (including DPP‑4 inhibitors, SGLT2 inhibitors, metformin, sulfonylureas, thiazolidinediones, GLP‑1 receptor agonists, and others). Agent selection in this program is driven by clinical factors such as glycemic control (commonly using HbA1c goals), relevant comorbidities (for example, cardiovascular disease, heart failure, or chronic kidney disease), tolerability, age and formulation needs (for instance, oral solutions when a member cannot swallow solids). This PA summary aligns coverage and authorization requirements with those clinical considerations and designates certain products as non‑preferred or subject to additional documentation to ensure appropriate, evidence‑based use.

Providers should note that the summary differentiates preferred versus non‑preferred agents across classes and that prior authorization requirements or documentation (including letters of medical necessity for many combination products) are used to confirm that therapy choice is appropriate for the member’s clinical situation.

Policy Revision Timeline

document_publishedLatest

Georgia Medicaid Fee-for-Service Antidiabetic Agents PA Summary published outlining PA criteria, preferred vs non-preferred agents, and prior authorization process (OptumRx).

Policy Summary

PayerGeorgia Department of Community Health

PolicyGeorgia Medicaid Fee‑for‑Service Antidiabetic Agents PA Summary

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

CVD-related indication.

Member is ≥18 years old; diagnosis of type 2 diabetes mellitus; HbA1c ≥ 7%; medication used to reduce risk of MACE in those with established cardiovascular disease AND member has experienced inadequate response, allergy, contraindication, drug-drug interaction, or intolerable side effects with Victoza or liraglutide and Ozempic.

CVD-related pathway with prior-agent requirements.

ContextThis lower age threshold applies specifically to the Invokana pediatric approval pathway; adult pathways use ≥18 years

inv-22: Adult age

Typical adult minimum age>= 18 years for most agent-specific approval pathways (e.g., alogliptin, Brynovin, Inpefa, Steglatro, Cycloset)

Exceptions notedSome agents have pediatric pathways (e.g., Invokana, Liraglutide, Mounjaro, Trulicity) with lower age limits

Documentation expectationClinical documentation should include age and diagnosis when requesting PA

inv-23: HbA1c (common threshold)

Standard HbA1c cutpoint for approvalsHbA1c ≥ 7% is required for coverage consideration for the majority of listed agents (glycemic and many CVD/renal indications)

Applies to multiple classesThreshold appears across DPP‑4, SGLT2, GLP‑1 and other agent-specific criteria (examples: alogliptin, Invokana, Liraglutide, Ozempic, Trulicity)

Used for both glycemic and outcome indicationsHbA1c ≥ 7% is required for glycemic control approvals and is included in many CVD/renal indication criteria

inv-35: HbA1c threshold (definitions)

Definition — policy thresholdHbA1c level of 7% or higher is required for coverage consideration for many listed approvals

Evidence in documentMultiple agent-specific entries explicitly state 'HbA1c level is 7% or higher' as a criterion (e.g., alogliptin, Liraglutide, Ozempic, Rybelsus, Soliqua)

ScopeUsed across pediatric and adult pathways where specified (agent-specific age limits still apply)

inv-36: Unable to swallow solids (oral solution indication)

Qualifying clinical condition'Unable to swallow solid oral dosage formulations' is an approvable clinical condition for Brynovin (sitagliptin oral solution)

Age requirement for BrynovinMember must be ≥ 18 years of age for Brynovin approval

Formulation-based indicationApproval is granted based on need for an oral solution formulation rather than on HbA1c or prior-agent failures

Approval frequently requires documented prior inadequate response, intolerance, contraindication, allergy, or drug–drug interaction to specified preferred agents (step therapy).

Examples: Rybelsus requires prior issues with dapagliflozin/Xigduo XR/Jardiance and a GLP-1 (Victoza/liraglutide, Mounjaro or Ozempic).
Inpefa requires failure/intolerance to dapagliflozin and empagliflozin.

Prior Authorization

Document required prior therapies/intolerances

Several agents require documentation that the member experienced inadequate response, allergies, contraindications, drug–drug interactions, or intolerable side effects to specified alternative agents before approval.

Cycloset: failure/intolerance to metformin plus three classes (sulfonylurea, thiazolidinedione, DPP-4 inhibitor, SGLT2 inhibitor).
Miglitol: inadequate response or intolerance to at least 2 preferred oral agents, one of which must be acarbose.

Documentation Required

Written letter of medical necessity required for many non-preferred or combination products

For many non-preferred combination or certain single-agent products, the prescriber must submit a written letter of medical necessity explaining why the separate preferred component products are not appropriate for the member.

Applies to products such as Janumet XR, Invokamet/Invokamet XR, Segluromet, Steglujan, Synjardy/Synjardy XR, Trijardy XR, pioglitazone/glimepiride generic, pioglitazone/metformin generic, metformin ER osmotic generic, and others listed.

Documentation Required

Include diagnosis, age, HbA1c and prior therapies in clinical documentation

Clinical documentation submitted with the PA should include the member's diagnosis (e.g., type 2 diabetes mellitus, heart failure, CKD, CVD), patient age, and HbA1c values when applicable, as well as documentation of prior therapy failures or intolerances.

Include HbA1c result when the criteria specify a threshold (commonly ≥ 7%).
Document age to confirm pediatric or adult approval pathways (e.g., ≥10 years or ≥18 years where specified).

Documentation Required

LOMN required for pioglitazone/metformin generic requests

For requests of the pioglitazone/metformin generic combination, the prescriber must submit a written letter of medical necessity stating why the separate preferred products (generic pioglitazone and generic metformin) are not appropriate for the member.

Denial Risk

Denial risk if letter of medical necessity not submitted for non-preferred combinations

Requests for many non-preferred combination products will be denied if the prescriber does not submit the required written letter of medical necessity explaining why separate preferred components are not appropriate.

Denial Risk

HbA1c ≥ 7% must be documented where required (denial risk if missing)

Several agent approvals require documented HbA1c ≥ 7%; failure to provide HbA1c documentation where required may result in denial of the PA request.

Examples: Alogliptin, Invokana, Steglatro, Cycloset and many GLP‑1 agents list HbA1c ≥ 7% as an approval requirement.

Billing Rule

Initiate prior authorization through OptumRx

Prior authorization requests must be initiated through the OptumRx prior authorization process; failure to obtain PA via OptumRx may result in denial of coverage.

PA initiation phone number: OptumRx 1-866-525-5827.