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Glucagon-like peptide-1 (GLP-1) agonists are anti-hyperglycemic medications administered by subcutaneous (SC) injection. These medications are indicated as an adjunct to diet and exercise to improve glycemic control in patients with Type 2 diabetes. GLP-1 agonists are incretin mimetic medications that bind and activate the human GLP-1 receptor. Activation of this receptor increases glucose-dependent insulin secretion by pancreatic beta-cells, suppresses glucagon secretion, and slows gastric emptying.
Please perform a formulary drug search on your patient’s member ID to ensure the prescription drug is covered under their benefit plan. The medication(s) in this medical policy may not be covered under a specific member’s benefit plan.
GLP-1 agonists require step therapy when purchased at a pharmacy. Sampling will not be acceptable for patient being on stable therapy.
Byetta® is not covered on BCBSMS closed formularies. Bydureon® and Tanzeum™ are not currently covered on any BCBSMS formulary.
BCBSMS covers Victoza® and Trulicity® with prior authorization when the member meets all of the criteria for ONE of the following conditions:
POLICY EXCEPTIONSStep therapy for GLP-1 agonists is not required for Federal Employee Program (FEP) and State Health Plan members.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
11/30/2012: New policy added. Effective 01/01/2013.
08/28/2015: Medical policy revised to add ICD-10 codes.
05/26/2016: Policy number L.5.01.428 added. Investigative definition updated in Policy Guidelines section.
06/13/2016: Approved by Pharmacy & Therapeutics (P&T) Committee.
09/30/2016: Code Reference section updated to add new ICD-10 diagnosis codes E13.37X1 - E13.37X9.
01/01/2017: Policy description revised. In policy section, added statement to perform a formulary drug search on patient's member ID to ensure prescription drug is covered under their benefit plan. Added statement that GLP-1 agonists require step therapy when purchased at a pharmacy. Added statements that Byetta® is not covered on BCBSMS closed formularies, and Bydureon® and Tanzeum™ are not currently covered on any BCBSMS formulary. Policy statement updated to remove Byetta and add Trulicity as covered with prior authorization when certain criteria are met. Policy exceptions updated to change "Byetta/Victoza" to "GLP-1 agonists." Sources section updated.
Byetta® Prescribing Information
Victoza® Prescribing Information
Trulicity® Prescribing Information
This may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
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