Concurrent use of DPP-4 inhibitors and GLP-1 agonists
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This policy implements a hard edit prohibiting concurrent pharmacy claims for GLP-1 agonists and DPP-4 inhibitors for Kentucky Medicaid members; it affects pharmacy providers submitting claims and prior authorization staff managing transitions. Applies to Kentucky Medicaid (MCO and FFS) as communicated by MedImpact.
A hard edit will deny claims for concurrent use of GLP-1 agonists and DPP-4 inhibitors and will no longer permit soft edit overrides with professional pharmacy services codes.
Coverage Criteria
inv-01: Not covered: Concurrent GLP-1 AND DPP-4 use
Not covered when concurrent active claims exist for both classes
Denials cannot be overridden at point-of-sale; exception requests will be dismissed.
inv-02: Covered with PA: One-time class transition
Allowed only for a one-time transition per drug class via prior authorization
Refer to the MedImpact Provider Portal for PA criteria and quantity limits.
DMS will not cover concurrent use of a GLP-1 agonist and a DPP-4 inhibitor. Concurrent therapy with both classes is excluded from coverage and claims for one class will be denied when there is an active claim for the other.
This exclusion is based on current ADA guidance that combination therapy with GLP-1 agonists and DPP-4 inhibitors is not recommended due to a lack of added clinical benefit. Because the combination has not demonstrated greater effectiveness, DMS considers concurrent use not medically necessary and will deny concurrent claims.
Routing and Coding
| BIN: 023880 | Benefit Identification Number for KY MCO |
| PCN: KYPROD1 | Processor control number for KY MCO |
| GROUP: KYM01 | Group for KY MCO |
| BIN: 026309 | Benefit Identification Number for KY FFS |
| PCN: KYPROD1 | Processor control number for KY FFS |
| GROUP: KYF01 | Group for KY FFS |
Provider Actions and Billing Impact
Prior authorization required for one-time class transition
A one-time transition fill per drug class may be approved through prior authorization to support members switching from one class to another. Refer to the MedImpact Provider Portal for PA criteria and quantity limits; contact MedImpact prior authorization by phone, fax, or the portal for submission.
- One-time transition per drug class allowed via PA
- See MedImpact Provider Portal for PA criteria and quantity limits
- Prior authorization submission via MedImpact phone/fax/portal
Hard edit: concurrent-class claims will deny and cannot be overridden
Denials for concurrent claims are hard edits effective August 29, 2025: claims for a GLP-1 agonist will deny when an active DPP-4 inhibitor claim exists for the same member, and vice versa; denials cannot be overridden at point-of-sale and exception requests will be dismissed.
- Hard edit denies concurrent GLP-1 and DPP-4 claims
- Point-of-sale overrides are not permitted; exception requests dismissed
Submit PA to document and authorize one-time transition
Providers must submit a prior authorization to support a one-time transition per drug class when switching between a GLP-1 agonist and a DPP-4 inhibitor; refer to the MedImpact Provider Portal for specific PA criteria and quantity limits.
- PA required to authorize the single transition fill per class
- Use MedImpact portal or prior authorization phone/fax for submission
Concurrent-use claims will deny and affect POS/exception workflows
Claims will deny if an active claim exists for the alternate class for the same member (GLP-1 vs DPP-4); these denials are hard edits and cannot be overridden at point-of-sale, which will impact pharmacy claim processing and exception handling.
- GLP-1 claim denies when active DPP-4 claim exists for same member
- DPP-4 claim denies when active GLP-1 claim exists for same member
- Denials cannot be overridden at POS; exception requests will be dismissed
Continuation / Transition Criteria
inv-13: Continuation/Transition
Transitioning members between classes
Providers must submit a prior authorization to support the transition; exception requests for concurrent use will be dismissed.
Quantity Limits
Definitions
Background
The American Diabetes Association guidance cited by MedImpact states that combining a GLP-1 receptor agonist with a DPP-4 inhibitor is not recommended because it does not provide additional clinical benefit. MedImpact implemented a hard edit effective August 29, 2025 to align coverage with this guidance and to prevent concurrent claims from being approved or overridden at point-of-sale.
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