Applies to Employer plans.
Covered (preferred drug)Qualification pathways
You can qualify through any one of these.
Type 2 Diabetes - Initial Approval
All of:
- Patient is ≥ 18 years of age
- Diagnosis of type 2 diabetes confirmed by lab values
Plus any one of:
- HbA1c ≥ 6.5%
- Fasting plasma glucose ≥ 126 mg/dL
- 2-hour plasma glucose ≥ 200 mg/dL
Automation Pathway - Non-Preferred Step Therapy Bypass
All of:
- ICD-10 code starting with E11.*
- History of metformin use (alone or in combination) within previous 130 days OR claims for oral antidiabetic medications (excluding single-agent metformin) within last 365 days AND history of metformin use within previous 130 days
- Patient is ≥ 18 years of age
Documentation to bring
- Diagnosis of type 2 diabetes (ICD-10 E11.*)
- Lab confirmation of T2DM: HbA1c ≥ 6.5%, OR fasting plasma glucose ≥ 126 mg/dL, OR 2-hour plasma glucose ≥ 200 mg/dL
- Documentation of patient age ≥ 18 years
Approval and renewal
- Initial approval: 6 months
- Renewal: every 12 months
Not covered when
- Weight loss without type 2 diabetes diagnosis
- Prediabetes/diabetes prevention without confirmed T2DM
- PCOS without type 2 diabetes
- Metabolic syndrome without type 2 diabetes
- Concomitant use with other GLP-1 agonists or GLP-1/GIP agonists
- Type 1 diabetes
Policy note: Automation criteria allow approval without manual review when ICD-10 E11.* codes are present AND metformin history within 130 days (or other oral antidiabetics within 365 days plus metformin within 130 days) is documented. For non-preferred medications, a history of one preferred medication within the 130-day look-back period is also required for automation. Step therapy requires trial of a preferred medication before non-preferred agents. The policy explicitly states that weight loss use (without T2DM) is NOT covered under this policy; Wegovy and Saxenda are separate products not included in this policy.
source: Medical Mutual Employer / Commercial Insurance prior authorization policy · View policy document (PDF)