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GLP-1 Agents Maximum Per Fill Limit

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Defines maximum per-fill quantities for specified GLP-1 receptor agonist products for Commonwealth of Kentucky Medicaid (Fee-for-Service and Managed Care) and describes prior authorization handling when requests exceed those limits.

Policy Summary

Payermedimpact

PolicyGLP-1 Agents Maximum Per Fill Limit

Policy CodePolicy N/A

Change TypeAdministrative quantity limits (no material clinical changes)

Effective DateFeb 1, 2025

Next Review DateN/A

Key ActionPrior authorization requests for quantities greater than the allowed per-fill limit will be dismissed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-02-01policy effective date

Fee-for-Service & Managed Carepopulations affected

Dismissedover-limit handling

Multiple productsper-fill limits enumerated

Per-Fill Quantity Limits for GLP-1 Agents

GLP-1 per-fill limits

Per-fill maximum quantities by drug (effective Feb 1, 2025):

BYDUREON BCISE 2 MG AUTOINJECT — Maximum per fill: 3.4 mL (4 autoinjectors).

BYETTA (EXENATIDE) 10 MCG DOSE PEN INJ — Maximum per fill: 2.4 mL (1 pen).

BYETTA (EXENATIDE) 5 MCG DOSE PEN INJ — Maximum per fill: 1.2 mL (1 pen).

LIRAGLUTIDE 18 MG/3 ML PEN — Maximum per fill: 9 mL (3 pens).

MOUNJARO (all listed strengths: 2.5, 5, 7.5, 10, 12.5, 15 mg/0.5 mL) — Maximum per fill: 2 mL (4 pens).

OZEMPIC (0.25–0.5 mg/dose pen; 1 mg/dose [4 mg/3 mL]; 2 mg/dose [8 mg/3 mL]) — Maximum per fill: 3 mL (1 pen).

RYBELSUS (3 mg, 7 mg, 14 mg tablets) — Maximum per fill: 30 tablets.

TRULICITY (all listed strengths: 0.75, 1.5, 3, 4.5 mg/0.5 mL) — Maximum per fill: 2 mL (4 pens).

VICTOZA (LIRAGLUTIDE) 2‑pak / 3‑pak 18 mg/3 mL pen — Maximum per fill: 9 mL (3 pens).

Product-Specific Quantity Details

Per-fill product quantity limits

BYDUREON BCISE 2 mg autoinject3.4 mL (4 autoinjectors)

BYETTA (EXENATIDE) 10 mcg pen2.4 mL (1 pen)

BYETTA (EXENATIDE) 5 mcg pen1.2 mL (1 pen)

LIRAGLUTIDE 18 mg/3 mL pen (Victoza)9 mL (3 pens)

MOUNJARO (all listed strengths)2 mL (4 pens)

OZEMPIC (various dose presentations)3 mL (1 pen)

RYBELSUS (3 mg, 7 mg, 14 mg tablets)30 tablets

TRULICITY (all listed strengths)2 mL (4 pens)

Prior Authorization Handling and Provider Notices

Prior Authorization

Over-limit prior authorizations will be dismissed

As this is an administrative edit, prior authorization requests for receiving more than the allowed quantity per fill will be dismissed.

Definitions — Maximum Quantity

Maximum per-fill definition

DefinitionThe maximum quantity of a specified GLP-1 product that may be dispensed in a single fill as defined in the document.

Effective dateEffective February 1, 2025

ScopeApplies to Commonwealth of Kentucky Medicaid Fee-for-Service and Managed Care members

Policy Summary

Payermedimpact

PolicyGLP-1 Agents Maximum Per Fill Limit

Policy CodePolicy N/A

Change TypeAdministrative quantity limits (no material clinical changes)

Effective DateFeb 1, 2025

Next Review DateN/A

Key ActionPrior authorization requests for quantities greater than the allowed per-fill limit will be dismissed.

SourceLink

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