Medicare AdvantageDecember 1, 2023
Glucagon-Like Peptide-1 prior authorization changes
Anthem Blue Cross (Anthem) wants to help ensure that members have access to medications with evidence to improve health and promote evidence-based, clinically appropriate use that align with FDA prescribing guidelines.
While Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists have gained popularity because of their weight loss effects, they are currently FDA-approved for diabetes only.
Wegovy® and Saxenda® are FDA-approved for weight loss only and not for treatment of diabetes. For the most part, our member benefits specifically exclude weight loss drugs, yet GLP-1 Receptor Agonists approved only for diabetes are being used off-label for weight loss and contributing to clinically inappropriate use. Compliance with prescribing guidelines is a requirement of Anthem network participation.
Beginning January 1, 2024, we will require verification of diagnosis of diabetes for Medicare members.
GLP-1 Agents (Adlyxin, Bydureon, Byetta, Ozempic, Rybelsus, Trulicity, Victoza) requests may be approved based on the following criteria:
- Individual has a diagnosis of type 2 diabetes; AND
- Written documentation has been provided that diagnosis has been verified by history of:
- Hemoglobin A1c (A1C) greater than or equal to 6.5%; OR
- Fasting Plasma Glucose (FPG) greater than or equal to 126 mg/dl (after fasting for at least 8 hours); OR
- Two-hour plasma glucose greater than or equal to 200mg/dl as part of an oral glucose tolerance test (75g oral glucose after fasting for at least 8 hours); OR
- Symptoms of hyperglycemia (including polyuria, polydipsia, polyphagia) or hyperglycemic crisis and a random plasma glucose greater than or equal to 200 mg/dl; AND
- Glucagon-like peptide-1 (GLP-1) receptor agonist may not be approved for the following:
- Weight loss {CMS exclusion}
You can access our drug lists and formulary policies by visiting Pharmacy Information for Providers | Anthem.com. Scroll down to Drug List Management and select Drug List Selection (anthem.com). Here you will be able to search for the policies based on the member’s health plan.
If you have questions, please contact Provider Services.
Anthem BC Health Insurance Company is the trade name of Anthem Insurance Companies, Inc. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross, Anthem Blue Cross Life and Health Insurance Company, and Anthem BC Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
CABC-CR-043750-23-CPN42761
PUBLICATIONS: December 2023 Provider Newsletter
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