New Documentation Requirements for Incretin Mimetics
To help ensure appropriate medication use and protect patient access, effective January 1, 2024, CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and all its subsidiaries and affiliates (collectively, “CareFirst”) will require submission of clinical documentation supporting a diagnosis of type 2 diabetes mellitus for members to obtain coverage for the following incretin mimetics: BYDUREON BCISE/BYETTA (exenatide), MOUNJARO (tirzepatide), OZEMPIC (semaglutide), TRULICITY (dulaglutide), RYBELSUS (semaglutide) and VICTOZA (liraglutide).
To help minimize the administrative burden for providers and ensure timely access to medications for our members, CareFirst is also enhancing the prior authorization review process for incretin mimetics. This new enhancement will provide a pathway for automated verification and approval using the diagnosis codes contained in a member’s medical claims history. Please help us to ensure that this automated verification process runs smoothly by accurately coding medical claims for members diagnosed with type 2 diabetes.
Important Note: For members whose plan includes weight loss medications as a covered benefit, glucagon-like-peptide-1 (GLP-1) medications that are FDA-approved to treat obesity are covered and must be obtained via specific prior authorization criteria that ensures appropriate use.
Additional information, including which medications require prior authorization, can be found online on our Pharmacy Prior Authorization page.
For questions about a prior authorization covered under the pharmacy benefit, please contact CVS Caremark at 855-582-2038.
For questions about FEP members and their prior authorization, please call 800-469-7556.
For general questions, please contact CareFirst Pharmacy Services at 800-241-3371.