Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists Prior Authorization Criteria
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MedImpact/Kentucky DMS prior authorization criteria for GLP-1 receptor agonists for members with Type 2 Diabetes Mellitus, including new renewal requirements emphasizing recent A1c lab monitoring; affects Kentucky Medicaid prescribers and MCO/FFS pharmacy prior authorizations.
New renewal criteria require submission of an A1c value within the past 6 months to support continued coverage for all GLP-1 receptor agonists.
Renewal criteria now explicitly require provider attestation of safety evaluation and demonstration of positive response to therapy.
Coverage excludes use of GLP-1 agents for anorexia, weight loss, or weight gain.
Non-preferred agents require prior trial and failure, intolerance, allergy, or contraindication to two preferred agents for initial approval.
Coverage Criteria for GLP-1 Receptor Agonists
Initial Therapy - Preferred
Preferred agents: Covered when ALL of the following are met for initial approval
Approval duration: 6 months
Renewal - Preferred
Renewal criteria - Preferred agents
Approval duration: 6 months
Initial Therapy - Non-preferred
Initial approval - Non-preferred / generic medically necessary
Approval duration: 6 months
Renewal - Non-preferred
Renewal criteria - Non-preferred agents
Approval duration: 6 months
Drugs prescribed specifically for anorexia, weight loss, or weight gain are excluded from coverage under this policy.
Use of GLP-1 receptor agonists for indications related to anorexia, weight loss, or weight gain is explicitly not medically necessary and is therefore excluded from coverage under this policy.
Provider Actions, Documentation, and Denial Triggers
Prior authorization required; approvals valid 6 months
Prior authorization is required for GLP-1 receptor agonists. Initial and renewal approvals are issued for 6 months; submissions for approval must include the required diagnosis and laboratory documentation described in the policy.
- Approval duration: 6 months for both initial and renewal requests
Step therapy — try two preferred agents before non-preferred
For initial approval of non-preferred agents, the provider must document a ≥3-month trial and failure, allergy, contraindication (including relevant drug–drug interactions), or intolerance to two preferred agents. Chart notes or claim history must confirm these trials.
- Trials must be ≥3 months each (trial and failure/intolerance/allergy/contraindication of two preferred agents)
- Provide chart notes or claim history to confirm trials
Required documentation — diagnosis and recent A1c
Submit clinical documentation with the prior authorization request including an ICD-10 diagnosis of Type II Diabetes Mellitus (chart notes within the past 12 months) and a hemoglobin A1c lab value within the past 6 months (or historical A1c correlating to T2DM plus a recent A1c).
- ICD-10 diagnosis of T2DM documented in chart notes within the past 12 months
- A1c lab value of ≥6.5% within the past 6 months, or historical A1c ≥6.5% plus an A1c within the past 6 months
Provider attestation required at renewal
Provider must attest at renewal that the patient has been evaluated for safety (for example, lacks treatment‑limiting adverse events) and demonstrates a positive response to therapy; this attestation is required as part of renewal documentation.
- Attest that patient evaluation for safety has occurred and that the patient shows positive response to therapy
Denial triggers — missing labs or prior‑trial documentation
Failure to provide required documentation—such as an A1c within the past 6 months, an ICD-10 T2DM diagnosis in chart notes within the past 12 months, or confirmation of required prior trials for non-preferred agents—may result in denial of the request.
- Missing A1c within past 6 months can trigger denial
- Lack of ICD-10 diagnosis/chart notes within past 12 months can trigger denial
- Absence of documented trials for non-preferred agents can trigger denial
Diagnosis Codes and Lab Criteria
| ICD-10 (unspecified) | ICD-10 diagnosis of Type II Diabetes Mellitus (chart notes within the past 12 months) — exact code(s) not listed in document |
Initial Therapy Requirements
Initial therapy requirements
Initial coverage rules
Renewal / Continuation Requirements
General continuation
Renewal/continuation requirements for covered GLP-1 agents
Step Therapy Requirements
| Step | Requirement | Evidence required | Notes |
|---|---|---|---|
| 1 | Patient must have trialed and had failure, intolerance, allergy, or contraindication to two preferred GLP-1 agents prior to approval of a non-preferred agent | Chart notes or claim history documenting ≥3-month trials and outcomes for two preferred agents (failure, intolerance, allergy, or contraindication) | Initial trials must be ≥3 months each; documentation must confirm the reason for discontinuation (failure, intolerance, allergy, or contraindication) |
Definitions and Contraindications
Background
GLP-1 receptor agonists are indicated for management of Type 2 Diabetes Mellitus (T2DM) and require monitoring of glycemic control. This policy requires documentation of a diagnosis of T2DM and recent glycemic data to support use. For renewals, the policy emphasizes submission of an A1c value within the past 6 months and a provider attestation that the patient has been evaluated for safety and demonstrates a positive response to therapy.
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