GLP-1 Medically Accepted Indication Update

A physician holds a vial of pills while taking notes at a computer.

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.

Condition Common ICD-10* codes1,2 Type 2 diabetes mellitus and other diabetes mellitus conditions E08.xx, E09.xx, E11.xx, E13.xx
*ICD-10 code list is not comprehensive. The coding information in this document is subject to changing requirements and should not be relied upon as official coding or legal advice. All coding should be considered on a case-by-case basis and supported by medical necessity and appropriate documentation in the medical record.

References:

  1. ICD-10-CM created by the National Center for Health Statistics under authorization by the World Health Organization (WHO). WHO is the copyright holder.
  2. The American Academy of Professional Coders.