ModifiedMass General Brigham Health PlanPolicy N/A

Glucagon-like Peptide-1 (GLP-1) Agonist for Diabetes Liraglutide

Prior authorization policy for outpatient pharmacy benefit coverage of GLP-1 receptor agonists (Trulicity, Ozempic, Rybelsus, Mounjaro, liraglutide) for treatment of type 2 diabetes for Commercial/Exchange members; defines initial and continuation criteria, quantity limits, duration limits, and concurrent-use restrictions.

Policy Summary

PayerMass General Brigham Health Plan

PolicyGlucagon-like Peptide-1 (GLP-1) Agonist for Diabetes Liraglutide

Policy CodePolicy N/A

Change TypeMODIFIED

Effective DateJul 1, 2025

Next Review Date

Key ActionIf the prescription does not meet the initial step therapy requirements at point of sale, submit a prior authorization request to the plan; prescriptions meeting initial step therapy adjudicate automatically.

SourceLink

POLICY UPDATE CHANGES

Moved restriction preventing use of GLP-1 indicated for weight loss in combination with GLP-1 used for type 2 diabetes from Limitations section into the criteria section.

Added liraglutide to the policy.

Removed Victoza due to availability of reference generic.

Clarified that the same GLP-1 does not bypass PA but claims history of other GLP-1 agents will bypass PA.

Added Mounjaro to criteria and limitations.

5Drugs in policy

24 monthsApproval Duration

MultipleConcurrent GLP-1 fills disallowed

Coverage Summary

Quantity and duration limits

Approval duration24 months

Trulicity quantity limit4 pens per 28 days

Ozempic quantity limit1 pen per 28 days

Mounjaro quantity limit4 pens per 28 days

Liraglutide quantity limit3 pens per 30 days

Rybelsus quantity limit30 tablets per 30 days

Initial Authorization Criteria

Initial Authorization

Authorization may be granted when the following criteria are met:

ALL of the following

A diagnosis of type 2 diabetes mellitus
Member will not use requested medication in combination with a GLP-1 indicated for the treatment of weight loss (e.g., Saxenda, Wegovy, Zepbound)

Note: Members with a claim history of any medication (excluding insulin and the same GLP1) for the treatment of Type 2 Diabetes mellitus will bypass PA

New-to-Plan Transition Authorization

Authorization may be granted for members new to the plan within the past 90 days who are currently receiving treatment, excluding when product is obtained as samples or via manufacturer's patient assistance programs

Member is new to the plan within the past 90 days

Member is currently receiving treatment with the requested product

Excludes use when product was obtained as samples or via manufacturer's patient assistance programs

Prior Authorization

New-to-plan member transition

Authorize members new to the plan within the past 90 days who are currently receiving the requested GLP-1 medication without additional criteria, provided the medication was not obtained as samples or via the manufacturer's patient assistance program.

Point-of-Sale PA Bypass

PA Bypass

Automatic bypass conditions

Members with a claim history of any medication (excluding insulin and the same GLP-1) for the treatment of Type 2 Diabetes mellitus will bypass PA

Prior Authorization

Submit prior authorization if point-of-sale requirements not met

Prescriptions that meet the initial step therapy requirements will adjudicate automatically at point of sale. If the prescription does not meet those initial step therapy requirements and therefore denies at point of sale, submit a prior authorization request to the plan for coverage.

Continuation (Reauthorization) Criteria

Continuation (Reauthorization)

Requests for reauthorization will be approved when the following criteria are met:

Prescriber attestation of continuation of therapy and positive response to therapy for the treatment of type 2 diabetes mellitus

Member will not use requested medication in combination with a GLP-1 indicated for the treatment of weight loss (e.g., Saxenda, Wegovy, Zepbound)

Documentation Required

Prescriber attestation for reauthorization

For reauthorization, the prescriber must attest that the member is continuing therapy and has had a positive response to treatment for type 2 diabetes mellitus.

Concurrent Use & Billing Rules

Concurrent-use policy restricts members from using the requested GLP-1 medication in combination with a GLP-1 agent indicated for weight loss (e.g., Saxenda, Wegovy, Zepbound) and prohibits filling more than one GLP-1 or more than one GLP-1 strength at the same time. Claims that violate these concurrent-use restrictions may be denied at point of sale or subsequently.

Billing Rule

Restrict concurrent fills

Members are restricted from filling more than one GLP-1 agent or more than one strength of a GLP-1 at the same time. Claims that violate this restriction may be denied.

No more than one GLP-1 agent may be filled concurrently.
No more than one strength of a GLP-1 may be filled concurrently.
Violating claims may be denied.

Applicable Drugs / Codes

Drugs covered under this policymixedCovered

Trulicity	dulaglutide; quantity limit = 4 pens per 28 days; prior authorization applies
Ozempic	semaglutide (injectable); quantity limit = 1 pen per 28 days; prior authorization applies
Rybelsus	semaglutide (oral); quantity limit = 30 tablets per 30 days; prior authorization applies
Mounjaro	tirzepatide; quantity limit = 4 pens per 28 days; prior authorization applies
Liraglutide	liraglutide; quantity limit = 3 pens per 30 days; prior authorization applies

Approval duration and concurrent-use summary

Approval Duration24 months

Concurrent GLP-1 fills disallowedMembers are restricted from filling more than one GLP-1 or more than one GLP-1 strength at the same time (multiple concurrent fills may be denied)

Clinical Evidence & Guidelines

Evidence and guideline basis: American Diabetes Association Standards of Medical Care in Diabetes - 2025 is referenced as the guideline supporting use of GLP-1 receptor agonists in type 2 diabetes.

Background

This pharmacy prior authorization policy governs GLP-1 receptor agonists for treatment of type 2 diabetes. It implements point-of-sale step therapy adjudication, with prescriptions that meet initial step therapy requirements adjudicating automatically and nonconforming prescriptions requiring submission of a prior authorization request. The policy applies point-of-sale step therapy bypass rules for members with prior claims history of other GLP-1 agents (excluding insulin and the same agent) and restricts concurrent use with GLP-1 agents approved for weight loss.

Definitions

Definitions:

PA bypass: Members with a claim history of any medication (excluding insulin and the same GLP-1) for treatment of type 2 diabetes will bypass prior authorization.

Revision History

06/26/2017reviewed

Policy reviewed.

03/18/2020reviewed

Policy reviewed.

06/22/2022created

Policy created and reviewed for June P&T; effective 10/01/2022.