Medicare Advantage prior authorization criteria changed for some diabetes drugs

We’ve changed our prior authorization criteria for glucagon-like peptide 1 agonist, or GLP-1, drugs indicated for diabetes for Medicare Plus Blue℠ and BCN Advantage℠ members who are beginning treatment with the brand-name medications listed below:

• Bydureon^®
• Byetta^®
• Ozempic^®
• Rybelsus^®
• Trulicity^®
• Mounjaro^®

Our prior authorization criteria require GLP-1 drugs to be used for the treatment of Type 2 diabetes, an indication approved by the U.S. Food and Drug Administration. Members must have a diagnosis of Type 2 diabetes for prior authorization to be approved, effective May 10, 2024.

In the past, the clinical requirement could be met through either a Type 2 diabetes diagnosis or a failed trial of one other diabetes medication on our drug list.The criteria update won’t apply to members who have started GLP-1 treatment prior to May 10, 2024. Those members will be exempt from this prior authorization update and will be able to remain on their GLP-1 medications without needing new prior authorizations.

For information on how to submit prior authorization requests electronically, click here.

For a complete list of covered drugs and associated requirements, go to 2024 Drug Lists.

See the additional article in this issue about a change to coverage criteria for other GLP-1 drugs for commercial fully insured members.