CurrentUnitedHealthcarePolicy N/A

Prior Authorization Criteria — GLP-1 Receptor Agonists and Combination Products

Governs prior authorization requests for GLP-1 receptor agonists and combination products for NC Medicaid and NC Health Choice beneficiaries, detailing required documentation, step therapy, and form submission requirements.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization — GLP-1 Receptor Agonists and Combinations

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the NC Medicaid/NC Health Choice Pharmacy Prior Approval Request form with prescriber signature and required clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Initial & ContinuationForm sections

Up to 365dMax therapy length

NC-specificJurisdiction

Coverage Criteria for GLP-1 Receptor Agonists

Initial Therapy

Covered when ALL of the following are met (Initial requests):

Initial criteria: Beneficiary has a diagnosis of Type 2 Diabetes.

Captured on PA form.

Initial criteria: Beneficiary had trial and failure or insufficient response to metformin-containing products OR has a documented contraindication/adverse event to metformin.

PA form asks both trial/failure and contraindication; one must be met.

Initial criteria: Beneficiary ASCVD and chronic kidney disease (CKD) status documented (yes/no).

Form collects ASCVD and CKD responses.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization — GLP-1 Receptor Agonists and Combinations

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the NC Medicaid/NC Health Choice Pharmacy Prior Approval Request form with prescriber signature and required clinical documentation.

SourceLink

On This Page

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Continuation Therapy

Continuation criteria — Covered when ALL of the following are met:

Continuation criteria: Documentation that the beneficiary has improved while on this medication (medical documentation should be attached).

Form requests attachment of medical documentation for continuation requests.

Continuation criteria: Individual clinical goals set by the provider are being met.

Provider documents goals on the PA form.

Continuation criteria: Beneficiary is continuing to make adequate progress towards treatment goals.

Must be answered on the continuation section of the PA form.

Provider Requirements, Documentation, and Denial Triggers

Prior Authorization

Prior Authorization Required

Prior authorization form and prescriber signature are required. Use the NC Medicaid/NC Health Choice Pharmacy Prior Approval Request form for GLP-1 receptor agonists and combinations; prescriber signature is mandatory.

Use NC Medicaid/NC Health Choice Pharmacy Prior Approval Request form
Prescriber signature required on the PA form

Step Therapy

Step Therapy Required for Non-Preferred Products

For non-preferred GLP-1 products, step therapy requires trial and failure or insufficient response to at least two preferred products before non-preferred therapy will be approved.

Must document trials of at least two preferred products with failure or insufficient response
If clinical reasons prevent trials of preferred products, provide justification and documentation

Documentation Required

Required documentation must be submitted with the prior authorization request. Attach clinical records demonstrating: diagnosis of Type 2 Diabetes; trial and failure of metformin or documented contraindication/adverse event to metformin; and when applicable, evidence of established ASCVD or chronic kidney disease.

Diagnosis: Type 2 Diabetes (Yes/No)
Metformin trial and failure OR documented contraindication/adverse event to metformin (provide details)
Documentation of established ASCVD (if applicable)
Documentation of Chronic Kidney Disease (if applicable)
For continuation requests, documentation of clinical improvement and progress toward individualized treatment goals

Denial Risk

Denial Triggers / Risks

Applications may be denied if required information is missing. Common denial triggers include absence of a Type 2 Diabetes diagnosis, lack of documentation of metformin trial or contraindication, missing step-therapy evidence for non-preferred products, or a prior authorization form without the prescriber signature.

Missing Type 2 Diabetes diagnosis
No documentation of metformin trial/failure or contraindication
No evidence of trials of two preferred products for non-preferred requests
Prior authorization form submitted without prescriber signature

Background

The form is intended to evaluate medical necessity for GLP-1 receptor agonist therapy in adults with Type 2 Diabetes. For initial requests, the form documents diagnosis of Type 2 Diabetes and asks about prior trial and failure or contraindication to metformin as part of establishing need for GLP-1 therapy. The form also captures trials of preferred GLP-1 products when applicable and requires prescriber attestation and supporting clinical information.

For continuation requests, the form requires documentation that the beneficiary has improved while on the medication, that individualized clinical goals are being met, and that the beneficiary is making adequate progress toward treatment goals; the prescriber signature and attached medical documentation are required to support ongoing coverage.

Definitions

Continuation request — definition and documentation expectations

DefinitionContinuation request: a request to continue therapy for a beneficiary already on the medication, requiring documentation of clinical improvement and progress toward treatment goals

Required documentationMedical documentation demonstrating that the beneficiary has improved while on this medication must be attached to the request

Clinical goalsConfirmation that individual clinical goals set by the provider are being met is required

Progress toward goalsDocumentation that the beneficiary is continuing to make adequate progress toward treatment goals is required

Prescriber signaturePrescriber signature and date required on the PA form

Initial request — definition and required documentation

DefinitionInitial request: a new therapy request for GLP-1 receptor agonists or combinations requiring specific baseline documentation

Type 2 Diabetes diagnosisThe prescriber must document that the beneficiary has a diagnosis of Type 2 Diabetes (Yes/No) on the PA form

Metformin trial or contraindicationDocument trial and failure or insufficient response to metformin-containing products, or document a contraindication/adverse event to metformin

ASCVD/CKD statusDocument whether beneficiary has established ASCVD and whether beneficiary has chronic kidney disease (Yes/No fields on the form)

Non-preferred product stepFor non-preferred products, document trial and failure or insufficient response to at least two preferred products or a clinical reason preferred products cannot be tried