CurrentUnitedHealthcarePolicy N/A

GLP-1 Receptor Agonists and Combinations (Initial and Continuation Requests)

Criteria and documentation checklist for prior authorization of GLP-1 receptor agonists and combination products for beneficiaries, covering initial and continuation requests and applicable clinical questions for Type 2 diabetes management.

Policy Summary

PayerUnitedHealthcare

PolicyGLP-1 Receptor Agonists and Combinations (Initial and Continuation Requests)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form documenting Type 2 diabetes diagnosis, metformin trial/failure or contraindication, ASCVD/CKD status, and attach medical documentation for continuation requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6initial intake clinical questions listed

3continuation request clinical assessment questions

7patient identifying fields on form

Coverage Criteria for GLP-1 Receptor Agonists

Initial Therapy

Covered when ALL of the following are met

Initial GLP-1 Authorization: 1) Beneficiary has a diagnosis of Type 2 Diabetes; 2) Beneficiary has had a trial and failure or insufficient response to metformin-containing products OR there is a documented contraindication or adverse event to metformin; 3) Documentation of presence or absence of established atherosclerotic cardiovascular disease (ASCVD); 4) Documentation of presence or absence of chronic kidney disease (CKD); 5) For non-preferred GLP-1 products, beneficiary has tried and failed or had an insufficient response to at least two preferred products OR there is a documented clinical reason preferred products cannot be tried.

Items correspond to checklist questions 1–6 on the prior authorization form.

Continuation Therapy

Covered for continuation when ALL of the following are met

Continuation Authorization: 1) Documentation that the beneficiary has improved while on the medication (medical documentation should be attached); 2) Individual clinical goals set by the provider are being met; 3) Beneficiary is continuing to make adequate progress toward treatment goals.

Policy Summary

PayerUnitedHealthcare

PolicyGLP-1 Receptor Agonists and Combinations (Initial and Continuation Requests)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Provider Actions, Documentation & Authorization Steps

Prior Authorization

Prior Authorization Requirements

Prior Authorization Required: Prior authorization must be submitted for GLP-1 receptor agonists and combination products. The prior authorization form must confirm a diagnosis of Type 2 diabetes and include completion of the trial/failure or contraindication questions regarding metformin. Prescriber signature is mandatory on the request.

Confirm Type 2 diabetes diagnosis on the form
Document trial and failure or insufficient response to metformin-containing products OR document contraindication/adverse event to metformin
For non-preferred products, document trial and failure or insufficient response to at least two preferred products or a clinical reason why preferred products cannot be used
Include beneficiary demographic information (name, ID, DOB, gender) and drug-specific details (drug name, strength, quantity per 30 days, requested length of therapy)
Prescriber signature is required

Denial Risk

Triggers for Denial

Denial Triggers: Requests that do not document required prior trials or contraindications, or that lack necessary clinical justification, are at high risk for denial.

Initial requests without documentation of metformin trial and failure or documentation of a contraindication/adverse event to metformin will be denied
For non-preferred products: failure to document trials of at least two preferred products or a documented clinical reason why preferred products cannot be used may result in denial
Missing prescriber signature or incomplete beneficiary/drug information may lead to denial

Documentation Required

Required Documentation

Required Documentation for Approval and Continuation: Attach medical records showing treatment response and attainment of individualized clinical goals. Continuation requests must include objective documentation of improvement or continued progress on therapy.

Initial requests: completed prior authorization form with answers to questions about Type 2 diabetes diagnosis and metformin trial/failure or contraindication, plus relevant clinical notes/labs supporting diagnosis
Continuation requests: medical documentation demonstrating improvement on therapy and that individualized clinical goals set by the provider are being met or the patient is making adequate progress
For non-preferred products: documentation of trials/failures of two preferred products or clinical justification why preferred agents are not suitable
Include beneficiary identifiers and drug details on all submissions (name, ID, DOB, drug name, strength, quantity, and length of therapy)

Background

The form is focused on management of Type 2 Diabetes with GLP‑1 receptor agonists and combination products. For initial requests it collects confirmation of diagnosis, whether the beneficiary has had a trial and failure or insufficient response to metformin-containing products or a documented contraindication/adverse event to metformin, and the presence of ASCVD and chronic kidney disease (CKD). For non‑preferred agents the form also requires documentation that the beneficiary has tried and failed at least two preferred products or a clinical reason preferred products cannot be used. For continuation requests the form requires documentation that the beneficiary has improved on therapy, that individual clinical goals are being met, and that the beneficiary is continuing to make adequate progress toward treatment goals.

OpenPayer

GLP-1 Receptor Agonists and Combinations (Initial and Continuation Requests)

Coverage Criteria for GLP-1 Receptor Agonists

Provider Actions, Documentation & Authorization Steps

Background

Definitions