Updated BCBSM Prior Authorization Criteria to Ensure Access to GLP-1 RAs for Patients with Type 2 Diabetes

• Being used for the treatment of Type 2 diabetes (T2D)
• Trial of one generic or preferred medication for the treatment of
  T2D
  • Note: Metformin and GLP-1 RA does not meet this criteria*

Please note, we announced a similar change that went into effect on February 1, 2023.

Patients that were new starts to T2D GLP-1 RA therapy (i.e., patients that did not have a pharmacy claim for the same GLP-1 RA drug identified in the previous 180-day period) were subject to the requirements outlined above starting on February 1, 2023.

Patients that were existing users of T2D GLP-1 RA therapy (i.e., patients that had a pharmacy claim for the same GLP-1 RA drug identified in the previous 180-day period) were able to continue coverage up until August 15, 2023 without having a confirmed diagnosis of T2D.

Effective August 15, 2023, all commercial users of T2D GLP-1 RA therapy (new starts AND existing users) are required to have a confirmed diagnosis of T2D for coverage.

Blue Cross and BCN understands that there is a proportion of patients who use GLP-1 RAs as first line treatment for T2D in order to reduce their cardiovascular and renal risk, as is concordant with current ADA guidelines. 

However, due to the recent shortages of Saxenda and Wegovy, which are FDA-approved for weight loss, there has been a growing number of members without a diagnosis of T2D who have started to use the diabetes labeled GLP-1 RA medications off-label for weight loss.  Unfortunately, this situation has caused downstream shortages of these diabetes labeled GLP-1 RA medications for patients who do have a diagnosis of T2D, resulting in them being unable to obtain their medication. Therefore, the goal in requiring a confirmation of the member’s diagnosis is to ensure that members with T2D have continued access to these therapies to avoid further shortages of this clinically necessary treatment.

1. Review the last one to two PCP visit notes and looks for a documented diagnosis code for the visit – if a T2D diagnosis code is found, then attest to the patient having T2D.
2. If no diagnosis code is found in the visit notes, review the problem list, and if T2D is listed, attest that the patient has T2D. 
3. If T2D is not listed in the problem list, then message the PCP and ask if the patient has T2D. If the physician says yes, then attest to the patient having T2D. If the PCP says no, or says the patient has prediabetes or obesity, then inform the PCP that the medication is no longer covered for these indications.  

As described above, Blue Cross and BCN currently implements 12-month auto-lookback on pharmacy claims to confirm the diagnosis of T2D. If a pharmacy claim is identified (excluding metformin or GLP-1 RA) in the last 12 months, a PA will NOT be required. In a brief review by Blue Cross and BCN approximately half of all commercial patients will meet the pharmacy claims auto-lookback criteria.

Beginning later this fall, Blue Cross and BCN will implement an auto-look back on medical claims. If a medical claim is found for T2D (any E11 code) in the last 12 months, a PA will NOT be required.

Also, given the August 15, 2023, changes, Blue Cross and BCN has begun doing their own medical review of patients on a GLP-1 RA that were grandfathered in as of February 1, 2023, due to having a prior GLP-1 RA prescription – if a T2D diagnosis code is found, they are flagged and will not require any further PA.