GLP-1 receptor agonist product switch limit
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Defines a limit on the number of times Kentucky Medicaid members may switch between GLP-1 receptor agonist products and describes prior authorization requirements for exceeding the limit; applies to Commonwealth of Kentucky Medicaid (Fee-for-Service and MCO) members and their providers.
The Commonwealth of Kentucky DMS will allow each member only two GLP-1 receptor agonist product switches per rolling year.
Coverage Criteria for GLP-1 Product Switches
GLP-1 product switch limit and exception
Covered when the following switch-count conditions are met:
Each change from one GLP-1 agent to a different GLP-1 agent counts as one switch.
Clinical documentation must justify additional switches.
This policy establishes a product-switch limit for Glucagon-Like Peptide-1 (GLP-1) receptor agonists for Kentucky Medicaid members. It applies to all switches between GLP-1 receptor agonist products and does not list any clinical exclusions. A change from one GLP-1 agent to a different GLP-1 agent is counted as one switch; each subsequent change counts cumulatively toward the limit. Members may switch GLP-1 products up to two (2) times per rolling 12-month period without additional documentation. Requests that exceed this limit require submission of clinical documentation to support the medical necessity of the requested therapy for prior authorization review.
Provider Requirements and Prior Authorization
Prior authorization contact and submission channels
Submit prior authorization requests to Kentucky MedImpact using the Provider Portal, phone, or fax. For MCO members use KYMCOPBM@MedImpact.com for program questions; Prior Authorization phone: (844) 336-2676 (8:00 AM–7:00 PM EST, 7 days/week); fax: (858) 357-2612; Portal: https://kyportal.medimpact.com/. For FFS members use KYMFFS@medimpact.com for program questions; Prior Authorization phone: (877) 403-6034 (8:00 AM–7:00 PM EST, 7 days/week); Portal: https://kyportal.medimpact.com/.
- MCO program questions: KYMCOPBM@MedImpact.com; PA phone: (844) 336-2676; PA fax: (858) 357-2612; Portal: https://kyportal.medimpact.com/ [[contact details in source]]
- FFS program questions: KYMFFS@medimpact.com; PA phone: (877) 403-6034; Portal: https://kyportal.medimpact.com/ [[contact details in source]]
How switches are counted
Each time a member is changed from one GLP-1 receptor agonist to a different GLP-1 receptor agonist counts as one switch; any subsequent change to another GLP-1 agent counts as an additional switch toward the two-switch limit.
- A change from 1 GLP-1 receptor agonist to another is counted as one switch.
- Any subsequent change to a different GLP-1 receptor agonist counts as an additional switch.
Documentation required for requests exceeding two switches
When requesting authorization for more than two GLP-1 product switches in a rolling 12‑month period, submit clinical documentation that supports the medical necessity and appropriate use of the requested therapy.
- Clinical documentation must justify the additional switch(es) beyond two within the rolling year.
- Documentation should be included with the prior authorization request for review.
Exceeding two-switch limit triggers required clinical justification
Requests for more than two GLP-1 product switches within a rolling year will require submission of clinical documentation supporting appropriate use of the requested therapy as part of the prior authorization review.
- Exceeding the two-switch limit triggers the requirement to provide clinical justification during PA.
- Failure to submit required documentation may result in denial of the request.
Definitions
Step Therapy / Switch Counting
| Step | Description | Action / Documentation |
|---|---|---|
| Third or subsequent GLP-1 product switch within the rolling 12-month period | ||
| Exceeds the two-switch limit (i.e., >2 switches per rolling year) | ||
| Requires submission of clinical documentation supporting appropriate use of the requested therapy for prior authorization review |
Background
Glucagon-like peptide-1 (GLP-1) receptor agonists are a class of medications used for glycemic control and weight management. To promote continuity of therapy and manage utilization within Kentucky Medicaid, this policy limits non-clinical frequent switching between GLP-1 agents. The document clarifies that a change from one GLP-1 product to another is counted as a single switch and that any additional change counts as another switch. Effective management under this policy relies on providers referencing the Kentucky Medicaid Preferred Drug List and using MedImpact’s Provider Portal or listed contact channels for prior authorization and questions.
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