CurrentUnitedHealthcarePolicy N/A

Prior Authorization/Notification: Diabetes Medications - GLP-1 & Dual GIP/GLP-1 Receptor Agonists

Prior authorization and notification requirements for GLP-1 and dual GIP/GLP-1 receptor agonist diabetes medications for UnitedHealthcare members; affects prescribers and pharmacy processing for covered drugs listed.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization/Notification: Diabetes Medications - GLP-1 & Dual GIP/GLP-1 Receptor Agonists

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2025

Next Review DateApr 1, 2025

Key ActionObtain prior authorization by submitting medical records confirming type 2 diabetes with one accepted laboratory criterion or documentation of diagnosis >2 years.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization duration

7medications covered

A1C ≥6.5%diagnostic criterion

2025-07-01effective

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Initial Authorization

Approved when ONE of the following is met:

Diagnostic laboratory evidence: Submission of medical records confirming type 2 diabetes mellitus as evidenced by one of: A1C >= 6.5% OR fasting plasma glucose (FPG) >= 126 mg/dL OR 2-hour plasma glucose >= 200 mg/dL during oral glucose tolerance test OR random plasma glucose >= 200 mg/dL in a patient with classic symptoms of hyperglycemiasee individual lab thresholds

Applies to new diagnoses; supporting chart notes required

Existing diagnosis documentation: For patients requiring ongoing treatment (diagnosed > 2 years), submission of medical records (e.g., chart notes) confirming diagnosis of type 2 diabetes mellitusdiagnosis > 2 years

Accepts chart notes as documentation

These GLP-1 and dual GIP/GLP-1 receptor agonist products are indicated and covered under this policy for glycemic control in type 2 diabetes mellitus when prior authorization criteria are met. They are not FDA approved for weight loss, and medications used primarily for weight loss are typically excluded from benefit coverage. Determination of coverage for weight‑loss use is made according to the member's prescription drug benefit plan and any applicable state or federal mandates.

Use of these agents when the intent is weight loss rather than glycemic control is generally excluded under this policy and is evaluated under the member's prescription drug benefit. Clinicians should document the indication as type 2 diabetes mellitus with the required medical records or laboratory evidence to support coverage; note that these agents are indicated as adjuncts to diet and exercise to improve glycemic control.

Coding and Diagnostic Criteria

Referenced coding sources and approvalsmixed

No codes listed

A1C threshold

A1C diagnostic threshold>= 6.5%

InterpretationOne accepted laboratory criterion to confirm type 2 diabetes mellitus for prior authorization.

Documentation requiredSubmit medical records (e.g., chart notes) showing the A1C result used for diagnosis.

Fasting plasma glucose threshold

Fasting plasma glucose threshold>= 126 mg/dL

Test conditionRequires fasting state for accurate measurement as an accepted diagnostic criterion.

Use in authorizationOne of the accepted lab values to confirm type 2 diabetes mellitus for prior authorization approval.

2-hour OGTT threshold

2-hour plasma glucose (OGTT) threshold>= 200 mg/dL during oral glucose tolerance test

Test typeMeasured 2 hours after a standardized oral glucose load (OGTT).

Role in documentationAcceptable laboratory evidence to support a type 2 diabetes diagnosis for prior authorization.

Random plasma glucose (with symptoms) threshold

Random plasma glucose with symptoms threshold>= 200 mg/dL in patient with classic symptoms of hyperglycemia or hyperglycemic crisis

Clinical contextRequires presence of classic hyperglycemia symptoms or hyperglycemic crisis to be diagnostic.

Use for authorizationAccepted laboratory criterion to confirm type 2 diabetes mellitus for prior authorization decisions.

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Approval will be granted when medical records (e.g., chart notes) confirm a diagnosis of type 2 diabetes mellitus by meeting ONE of the following laboratory criteria: A1C ≥ 6.5%; fasting plasma glucose (FPG) ≥ 126 mg/dL; 2‑hour plasma glucose ≥ 200 mg/dL during an oral glucose tolerance test; or random plasma glucose ≥ 200 mg/dL in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis. For patients with an established diagnosis > 2 years, submission of medical records confirming the diagnosis is also acceptable. Authorization is typically issued for 12 months.

Affected products: Bydureon BCise, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza
Note: Brand Victoza is typically excluded from coverage

Documentation Required

Documentation Requirement and Denial Risk

Submit supporting medical records (e.g., chart notes) that document the diagnostic criteria used to establish type 2 diabetes mellitus. Lack of submitted or adequately detailed medical records confirming the diagnosis may result in denial of the request.

Required documentation: medical records demonstrating one of the listed laboratory values or chart documentation of an established diagnosis (>2 years)

Note

Utilization Management Note

Utilization management programs may affect approval and reauthorization decisions. UnitedHealthcare may approve initial and reauthorization requests based solely on previous claim/medication history, diagnosis codes (ICD‑10) and/or claim logic through automated approval processes. Supply limits and other utilization constraints (e.g., step therapy) may apply.

Supply limits may be in place
Automated approvals/re-approvals may be used based on claims history and diagnosis codes

Background

GLP‑1 receptor agonists and the dual GIP/GLP‑1 receptor agonist tirzepatide are indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Several agents listed (Bydureon BCise, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza) are indicated only for treatment of type 2 diabetes and are not FDA‑approved for weight loss. Some products also have additional FDA indications—examples include cardiovascular risk reduction (Ozempic, Trulicity, Victoza) and renal outcomes for Ozempic—but these agents remain within the scope of diabetes-related indications for coverage under this policy.

Definitions

Diagnostic criteria supporting diagnosis

Accepted diagnostic criteria (any one)A1C >= 6.5% OR Fasting plasma glucose (FPG) >= 126 mg/dL OR 2-hour plasma glucose >= 200 mg/dL during OGTT OR Random plasma glucose >= 200 mg/dL with classic hyperglycemia symptoms

Documentation optionsSubmit medical records (e.g., chart notes) showing the laboratory value used to confirm the diagnosis; for ongoing treatment, charts demonstrating diagnosis >2 years may be accepted.

PurposeUsed to verify type 2 diabetes mellitus for prior authorization of GLP-1 and dual GIP/GLP-1 receptor agonists.

Related noteThese agents are indicated as adjuncts to diet and exercise to improve glycemic control in type 2 diabetes and are not FDA-approved for weight loss.

Initial Therapy Criteria

Initial therapy

Initial approval requirements

Lab-confirmed diagnosis: Submit medical records showing one accepted diagnostic lab value: A1C >= 6.5% OR FPG >= 126 mg/dL OR 2-hour PG >= 200 mg/dL during OGTT OR random plasma glucose >= 200 mg/dL with classic hyperglycemia symptomssee thresholds

Alternatively, for ongoing treatment, provide records showing diagnosis > 2 years

Continuation / Re-authorization Criteria

Re-authorization

Re-authorization: Authorization will be issued for 12 months; UnitedHealthcare may approve re-authorization based on previous claim/medication history, diagnosis codes, and/or claim logic12 months

Automated processes may be used

Program / Note
Other utilization management programs or step therapy may apply per plan; supply limits may be in place. UnitedHealthcare may approve initial and re-authorization based solely on previous claim/medication history, diagnosis codes (ICD-10) and/or claim logic; use of automated approval and re-approval processes varies by program and/or therapeutic class.