CurrentUnitedHealthcarePolicy N/A

Pa Glps Pa Form

Prior authorization form and clinical criteria for GLP-1 receptor agonist coverage for multiple indications (diabetes, OSA, MACE, MASH, and other non-diabetes indications) including initial and renewal requirements and preferred vs non-preferred agent rules. Excludes use for overweight/obesity and discontinues coverage of Saxenda (liraglutide).

Policy Summary

PayerUnitedHealthcare

PolicyPa Glps Pa Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 2, 2026

Next Review Date

Key ActionFax the completed GLP-1 Receptor Agonists prior authorization form with required clinical documentation (including DX code and indication-specific support) to DHS - Pharmacy Division.

SourceLink

POLICY UPDATE CHANGES

No material changes

SaxendaSaxenda removed

ObesityObesity excluded

MultipleConditional indications

3/2/2026Form effective

Coverage Summary

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Payer: DHS — Policy title: GLP-1 Receptor Agonists prior authorization form (form effective 3/2/2026). Scope: prior authorization form and clinical criteria for coverage of GLP-1 receptor agonists across multiple indications including diabetes, obstructive sleep apnea (OSA), reduction in risk of Major Adverse Cardiovascular Events (MACE), noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH), and other non-diabetes indications. The form defines initial and renewal requirements and preferred vs non-preferred agent rules. It explicitly excludes use for overweight/obesity and Saxenda (liraglutide) will no longer be covered. Coverage stance: mixed (conditional coverage across multiple non-diabetes indications with specific documentation, trial and threshold requirements).

Key thresholds

BMI for OSA>= 35 kg/m2

BMI for MACE>= 27 kg/m2

Rezdiffra trial duration (MASH)>= 12 months

Weight-loss response threshold for OSA renewal>= 5% total body weight loss after >=3 months at maximum tolerated dose

Duration for documented OSA improvement>= 1 year

Medical-Necessity Criteria (Initial and Renewal)

General exclusions and note

ALL of the following

GLP-1 Receptor Agonists are not covered for the treatment of overweight or obesity.
Saxenda (liraglutide) will no longer be covered for any indication.

Initial requests - For the treatment of diabetes

Preferred vs Non-preferred

For a PREFERRED GLP-1 Receptor Agonist for the treatment of diabetes, submit documentation of the beneficiary's diagnosis.
Non-preferred agent requirements: For a NON-PREFERRED GLP-1 Receptor Agonist for the treatment of diabetes: Has tried and failed or has a contraindication or an intolerance to the preferred GLP-1 Receptor Agonists.

Initial requests - For all other diagnoses except diabetes (General requirement)

Requested GLP-1 RA must be used in combination with lifestyle changes and behavioral modifications unless specified otherwise in indication-specific sections.

The requested GLP-1 Receptor Agonist will be used in combination with lifestyle changes and behavioral modifications.

Initial requests - Treatment of moderate to severe obstructive sleep apnea (OSA)

All of the following must be met:

ALL of the following

Has a recent BMI greater than or equal to 35 kg/m2BMI >= 35 kg/m2
Has a diagnosis of moderate to severe OSA
Has excessive daytime sleepiness or reduced sleep-related quality of life
Is adherent to positive airway pressure (PAP) treatment or is currently using or is intolerant to an oral appliance for OSA
Had a recent six-month trial of and plan to continue lifestyle changes and behavioral modifications OR a medical reason why immediate treatment is necessary

Initial requests - Reduction in risk of Major Adverse Cardiovascular Events (MACE)

All of the following must be met:

ALL of the following

Has a recent BMI greater than or equal to 27 kg/m2BMI >= 27 kg/m2
Has established cardiovascular disease (e.g., history of MI, stroke, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease or has intermittent claudication with an ABI <0.85 at rest)
Is receiving optimized pharmacotherapy for established cardiovascular disease based on current consensus guidelines
The requested GLP-1 Receptor Agonist will be used in combination with lifestyle changes and behavioral modifications

Initial requests - Treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH)

All of the following must be met:

ALL of the following

Has a diagnosis of MASH with moderate to advanced liver fibrosis (consistent with stage F2 or F3 fibrosis)
Does not have significant alcohol use or alcohol dependence
Is receiving optimized pharmacotherapy for established comorbid diseases based on current consensus guidelines
If currently taking Rezdiffra (resmetirom) with a plan to add concomitant therapy with a GLP-1 Receptor Agonist, failed to show improvement in liver fibrosis after a trial of Rezdiffra (resmetirom) for greater than or equal to 12 monthsRezdiffra trial >= 12 months

Renewal / Continuation criteria - For all diagnoses except diabetes (general)

Continuation requires documentation described in indication-specific sections; general requirement to continue lifestyle changes.

Is continuing lifestyle changes and behavioral modification (e.g., healthy diet and increased physical activity)

Renewal - Reduction in risk of MACE

Is receiving optimized pharmacotherapy for established cardiovascular disease based on current consensus guidelines

Renewal - MASH

If beneficiary has been using GLP-1 RA for >= 1 year must have one of the following:

ANY of the following

Resolution of steatohepatitis AND improvement or no worsening of liver fibrosis
Improvement of liver fibrosis AND no worsening of steatohepatitis

Does not have significant alcohol use OR alcohol dependence

Is receiving optimized pharmacotherapy for established comorbid diseases based on current consensus guidelines

Renewal - OSA

Criteria depend on duration of GLP-1 RA use and documented response/adherence:

Duration-based pathways

Using GLP-1 RA for LESS THAN SIX MONTHS: Has been using the GLP-1 Receptor Agonist for LESS THAN SIX MONTHS and has documentation of lifestyle changes and behavioral modifications (e.g., healthy diet and increased physical activity)
Using GLP-1 RA for SIX MONTHS OR LONGER
- If initial dose titration has been completed and the beneficiary has been using the GLP-1 Receptor Agonist for at least three consecutive months at the maximum tolerated dose, has 5% total body weight loss and documentation of dietary changes>= 5% total body weight loss after >=3 months at max tolerated dose
- If initial dose titration has not been completed and/or the beneficiary has been using the GLP-1 Receptor Agonist for less than three consecutive months at the maximum tolerated dose, has documentation of dietary changes

Non-preferred agent criteria for non-diabetes diagnoses

For a non-preferred GLP-1 RA, indicate trials or contraindications to the following agents:

ANY of the following

Ozempic (semaglutide) injection has been tried or cannot be tried
Wegovy (semaglutide) injection has been tried or cannot be tried
Mounjaro (tirzepatide) injection has been tried or cannot be tried
Zepbound (tirzepatide) injection has been tried or cannot be tried

Coding

Diagnosis codes (DX code required on form)ICD-10

No codes listed

Listed GLP-1 receptor agonist product names (used in trial/step criteria)mixed

Ozempic	semaglutide injection (preferred or non-preferred depending on plan)
Wegovy	semaglutide injection
Mounjaro	tirzepatide injection
Zepbound	tirzepatide injection
Saxenda	liraglutide — specifically stated will no longer be covered
Rezdiffra	resmetirom — referenced for MASH concomitant therapy assessment

No codes listed

Provider Actions

Prior Authorization

Submit completed prior authorization form and clinical documentation

Fax the completed GLP-1 Receptor Agonists prior authorization form with required clinical documentation to DHS - Pharmacy Division. Be sure to include the beneficiary diagnosis and the DX code (DX code required) on the form. Include supporting documentation per the indicated diagnosis/indication as requested on the form.

Documentation Required

Document diagnosis and prior trials

Document the beneficiary's diagnosis and prior trials as applicable: for diabetes, submit documentation of the diabetes diagnosis; for a non-preferred GLP-1 RA for diabetes, document a trial and failure or contraindication/intolerance to preferred GLP-1 RAs. For non-diabetes indications, include indication-specific documentation such as BMI, OSA severity, PAP adherence or intolerance, MASH fibrosis staging, and results of Rezdiffra (resmetirom) trial when relevant.

Documentation Required

Demonstrate lifestyle modification efforts

Document recent trials of lifestyle changes and behavioral modifications (e.g., healthy diet and increased physical activity). This documentation is required for initiation and for continuation/renewal for all non-diabetes indications and is specifically required for OSA initial and renewal criteria and for other non-diabetes pathways.

Background

Background: This prior authorization form operationalizes coverage rules for GLP-1 receptor agonists referenced to FDA-approved labeling and other medically accepted indications. It specifies required clinical documentation, diagnosis coding (DX code required), and trial/step requirements to distinguish preferred versus non-preferred agents. The form requires indication-specific documentation (for example: BMI and OSA severity and PAP adherence for OSA; optimized pharmacotherapy and BMI for MACE risk reduction; fibrosis staging and Rezdiffra trial results for MASH). It also requires documentation of lifestyle changes and behavioral modification where indicated, and it excludes use for overweight/obesity; Saxenda (liraglutide) is explicitly no longer covered. Submit the completed PA form and required clinical documentation by fax to DHS - Pharmacy Division.

Definitions

MACEMajor Adverse Cardiovascular Events

MASHNoncirrhotic metabolic dysfunction-associated steatohepatitis

PAPPositive airway pressure

Revision History

2026-03-02Effective DateLatest

Form effective

Policy Summary

PayerUnitedHealthcare

PolicyPa Glps Pa Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 2, 2026

Next Review Date

Key ActionFax the completed GLP-1 Receptor Agonists prior authorization form with required clinical documentation (including DX code and indication-specific support) to DHS - Pharmacy Division.

SourceLink

On This Page

6-month lifestyle trial or medical reason