GLP-1 (glucagon-like-peptide-1) medications.

Understanding your health plan’s coverage

• Diabetes
• Sleep apnea (when breathing starts and stops repeatedly while sleeping)
• Weight management

Which GLP-1 medications are covered for diabetes?

• Trulicity (dulaglutide) – preferred drug
• Mounjaro (tirzepatide)
• Ozempic (semaglutide)
• Byetta (exenatide)
• Victoza (liraglutide)

For these medications to be covered by the US Family Health Plan, your physician will need to fill out a Prior Authorization form. Some of the questions on this form are:

• Does the member have Type 2 Diabetes?
• Has the member tried metformin before and has it not worked for them?

Which GLP-1 medications are covered for sleep apnea?

• Zepbound (tirzepatide)

For these medications to be covered by the US Family Health Plan, your physician will need to fill out a Prior Authorization form. Some of the questions on this form are:

• Does the member have moderate to severe sleep apnea?
• Does the member have a body mass index (BMI) greater or equal to 30?
• Is the member 18 years old or older?

Which GLP-1 medications are covered for weight management?

• Wegovy (semaglutide) – preferred drug
• Zepbound (tirzepatide) – preferred drug
• Saxenda (liraglutide)

For these medications to be covered by the US Family Health Plan, your physician will need to fill out a Prior Authorization form. Some of the questions on this form are:

• For patients 18 years or older:
  • Does the member have a BMI greater than or equal to 30 or a BMI greater than 27 with other health problems?
  • Has the member tried a medication like phentermine before and has it not worked for them?
• For Patients 12-17 years old:
  • Is the prescription for the Wegovy injection?
  • Does the member have a BMI greater than 95% of children their age?

Other information that is needed for coverage of GLP-1’s used for weight management and sleep apnea are:

• Has the member been watching their diet and participating in exercise for at least 6 months?
• Is the prescriber an in-network provider with the US Family Health Plan?

If coverage is approved, how long is my prior authorization good for?

If approved for diabetes:

• There is no expiration date.

If approved for sleep apnea:

• Coverage is good for 1 year.
• After 1 year, your physician will have to provide updated notes for approval showing:
  • Your sleep apnea symptoms have gotten better.

If approved for weight management:

• Coverage is good for 1 year.
• After 1 year, your physician will have to provide updated notes for approval showing:
  • You have continued to exercise and watch your diet.
  • For patients 18 years and older, you have lost 5% of your starting weight.
  • For patients 12-17 years, you have lost 4% of your starting weight.

It is important to know that information needed for coverage can change throughout the year. Make sure that, if you have another insurance besides the US Family Health Plan, your pharmacy has this information on file. You will need to bill the other insurance first and have your physician get prior authorization from them if needed.

Did you know our Martin’s Point Mail-Order Pharmacy can ship these GLP-1 medications?

• You can receive a higher-quantity day supply
  • Up to 60 days for GLP-1 medications used for sleep apnea and weight management
  • Up to 90 days for GLP-1 medications used for diabetes
• You will be charged 1 copay.