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Provider updates

Key Changes to PA Criteria for Diabetes Medications Effective 12/1/2022

Feb 24, 2023, 17:16 PM

Changes to both the GLP-1 agonist and SGLT2 inhibitor PA criteria were made at the last CareOregon P&T committee. The GLP-1 agonist criteria changes remove the requirement for insulin therapy prior to GLP-1 therapy for certain members. Though SGLT2 inhibitors are typically used for diabetes, certain medications in class like Farxiga also have an indication for chronic kidney disease (CKD). The criteria changes for the SGLT2 inhibitors are limited to the CKD indication. Changes are summarized below.

GLP-1 Agonists

  • Long-acting insulin will no longer be required as a part of PA criteria for members with an A1c between 7% and 10%.
  • Failure of insulin will still be required for members with an A1c >10%.
  • For members with A1c >10% we will still continue to accept medical rationale for avoiding insulin therapy on a case-by-case basis, such as morbidly obese patients with a concern for weight gain on insulin therapy.
  • The requirements for failure of metformin plus two other oral agents remain the same for all members.

SGLT2 Inhibitors

  • Urine albumin to creatinine ratio (uACR) is a lab that measures albumin in the urine and can be an early marker of chronic kidney disease. Patients may have an elevated uACR prior to having a significant decline in estimated glomerular filtration rate (eGFR), another measure of CKD.
  • Criteria have changed to allow uACR >30 mg/g as a marker of CKD that will allow for coverage of Farxiga. Now providers can submit documentation of stage 2-4 CKD, eGFR 25-75 mL/min/1.73 m2OR uACR > 30 mg/g as evidence of CKD.
  • Members also must be taking the highest tolerated dose of an ACE inhibitor or ARB per criteria.

Bottom Line

  • For members with an A1c between 7% and 10%, failure of insulin is no longer required prior to approval of a GLP-1 agonist, allowing GLP-1 agonists to be the first injectable therapy after failure of metformin plus two other oral therapies.
  • uACR is a new tool in the toolbox for providers to measure for severity of CKD.

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