Diagnosis requirements for glucagon-like peptide-1 (GLP-1) agonists:
Effective June 1, 2023, Humana will require pharmacies to enter a diagnosis code for a medically accepted indication supplied by the prescriber when processing a prescription claim for a GLP-1 receptor agonist for Humana-covered patients. Beginning on the above date, please include the diagnosis on the GLP-1 prescription to minimize delays in dispensing the medication.
GLP-1 agonists are indicated for type 2 diabetes treatment. They also have shown benefits for obesity and weight management treatment. However, weight loss is excluded from coverage on Humana commercial and MAPD/PDP plans, so GLP-1 agonists will not be covered for this use.
GLP-1 agonists currently approved by the U.S. Food and Drug Administration (FDA) for type 2 diabetes mellitus treatment as an adjunct to diet and exercise include:
- Adlyxin® (lixisenatide)
- Bydureon® (exenatide)
- Byetta® (exenatide)
- Mounjaro® (tirzepatide)
- Ozempic® (semaglutide)
- Rybelsus® (semaglutide)
- Trulicity® (dulaglutide)
- Victoza® (liraglutide)
GLP-1 agonists currently approved by the FDA for obesity and chronic weight management treatment as an adjunct to a reduced-calorie diet and increased physical activity include:
- Saxenda® (liraglutide)
- Wegovy® (semaglutide)
Prescribers with questions regarding this change can call 800-555-CLIN (2546), Monday ─ Friday, 8 a.m. ─ 8 p.m., Eastern time. Prescribers in Puerto Rico should call 866-488-5991, Monday ─ Friday, 8 a.m. ─ 8 p.m., Eastern time.
Please see the table below for a list of common International Classification of Diseases, 10th Revision (ICD-10) codes corresponding to the conditions outlined in this communication.
- ICD-10-CM created by the National Center for Health Statistics under authorization by the World Health Organization (WHO). WHO is the copyright holder.
- The American Academy of Professional Coders.