Reminder: GLP-1 Utilization Management

By September 1, 2025: (1) Billing and authorization teams must update systems to require prior authorization for ALL GLP-1 medications (all NDCs/formulations) before claims are submitted. (2) Clinical staff must verify that prescribing providers are authorized to treat diabetes per plan requirements before processing claims. (3) Update claim submission workflows to check patient plan formularies for weight loss medication exclusions; if excluded, deny claims for Zepbound and Wegovy even when billed with OSA or MACE reduction diagnoses, since coverage is determined by drug classification, not indication. (4) Front desk and authorization staff should educate patients that Zepbound and Wegovy may not be covered under their plan regardless of diagnosis if anti-obesity agents are excluded. (5) Coordinate with Provider Relations to communicate these requirements to all prescribing providers, emphasizing the September 1 deadline for provider authorization verification. Failure to obtain prior authorization before claims submission will result in claim denials. Note: This policy applies only to Commercial and Exchange (ACA) plans; Medicare and Medicaid claims are excluded.