Aetna (Commercial and MA)
Changed from No Info to Not Covered
Blue Cross Complete Medicaid
Changed from No Info to Non-preferred, PA required
All GLP-1 RAs
Beginning August 15, 2023, all GLP-1 RAs will require a prior authorization process:
1. Claims auto-lookback at “point-of-sale” for either a.) previous pharmacy claim for Ty2D drug (except for metformin or another GLP-1 drug) OR b.) diagnosis code denoting T2D in medical claims history.
What's a "claims auto-lookback?" scroll down for an explaination.
2. If one of those criteria is met, no PA is required. If one or more of those criteria are not met, PA will be triggered. If required, the prescriber can check a box via electronic prior auth (ePA) to confirm that the member has T2D for coverage
Step therapy supplemental document updated as of 6/1/23
Added Appendix link to Wegovy PA policy from 8-2022
Changed from Preferred to Non-preferred (for PPO and HMO plans)
Changed from Non Preferred PA to Not Covered
Medicaid BCC, HAP, McLaren, Meridian, Molina, Priority
Changed from Non Preferred PA to Not Covered
Priority Traditional & Optimized
As of July 1st, under pharmacy benefit, beneficiary must have a prescription claim for insulin within the last six months.
Removed “unknown designation” and updated with June 1 2023 policy criteria: 1.) The beneficiary is under the care of an endocrinologist, a physician, or a non-physician practitioner (nurse practitioner, physician assistant, or clinical nurse specialist) who is managing their type 2 diabetes.
2.) The beneficiary is prescribed and uses insulin or an insulin pump
3.) The beneficiary tests blood glucose 2x or more per day 4.) The beneficiary or their caregiver is educated on the use of the device and is willing and able to use the CGMS.
We utilize auto-lookback at point of sale for BCBSM members with commercial coverage.This means that when the patient picks up their diabetes GLP-1 drug from the pharmacy, the system will automatically check whether the member has a previous pharmacy claim for a Type 2 diabetes drug (except for metformin or a GLP-1 drug) OR a diagnosis code denoting Type 2 diabetes in their medical claims history. The lookback is a 12-month retrospective period.If the member meets either of these criterion at point of sale, the diabetes GLP-1 claim will pay, and no PA is required. If the member does not meet either of these criterion at point of sale, a prior authorization will be required for coverage.If a PA is required, the prescriber can simply check a box via electronic prior authorization (ePA) to confirm that the member has Type 2 diabetes for coverage.
Providers can request coverage for the diabetes GLP-1 products through electronic prior authorization (ePA).As noted above, we require that the provider attest that the member has a diagnosis of Type 2 diabetes if that member does not meet the automatic lookback criteria at point of sale. On the ePA form, the provider is asked to answer the following question via a “Y” or “N” checkbox: “Does the patient have a diagnosis of Type 2 diabetes?”For instructions on how to submit an ePA, please refer to our public website here: For Providers: Authorization and step therapy | BCBSM.Please note that as of June 1, 2023, Public Act 60 now requires all providers in the state of Michigan to utilize ePA for all PA requests.
Answer: We originally implemented the automatic pharmacy claims lookback for the diabetes GLP-1 drugs on February 1, 2023 for commercially insured members who were new starts to diabetes GLP-1 therapy. However, we also grandfathered-in members who were already taking these drugs.When we grandfathered-in the members who were already utilizing these products, they were not required to provide proof of diagnosis. It is possible that certain members who were grandfathered-in to coverage do not actually have an appropriate diagnosis of Type 2 diabetes, and may have been using the GLP-1 drugs indicated for T2D off-label for weight loss. Therefore, starting August 15, we will require the members who were previously grandfathered-in to provide proof of Type 2 diabetes diagnosis to prevent any further off-label use of the diabetes GLP-1 products.To answer your second question, yes, if a patient is being switched to a different GLP-1 product, they will be required to meet the lookback criteria at point-of-sale for coverage, OR have their provider submit an ePA to confirm their diagnosis if they do not meet the automatic lookback criteria.Additionally, the changes described above for 8/15 apply to the following GLP-1 products:
*Byetta and Bydureon are Nonformulary (not covered) for members with Custom, Custom Select, or Clinical pharmacy drug formularies. Byetta and Bydureon are only covered for members with the Preferred Drug List formulary.