Pharmacy Prior Authorization Criteria

Diabetic GLP-1's

Indications for Prior Authorization

Bydureon BCise

• Adjunctive therapy to diet and exercise to improve glycemic control in adults and pediatric patients aged 10 years and older with type 2 diabetes mellitus
  

Byetta, Rybelsus, Mounjaro

• Adjunctive therapy to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus
  

Ozempic, Trulicity

• Adjunctive therapy to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus
  

• To reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with type 2 diabetes mellitus and established cardiovascular disease
  

Victoza

• Adjunctive therapy to diet and exercise to improve glycemic control in adults and pediatric patients 10 years of age and older with type 2 diabetes mellitus
  

• To reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with type 2 diabetes mellitus and established cardiovascular disease
  

Criteria

Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Generic liraglutide, Mounjaro

Prior Authorization (Initial Authorization)

Length of Approval: 1 Year(s)
For diagnosis of Diagnosis of type 2 diabetes mellitus (DM2)

• Patient has a documented diagnosis of type 2 diabetes mellitus as evidenced by medical records documenting one of the following:
• A1C ≥ 6.5%
• Fasting plasma glucose (FPG) ≥ 126 mg/dL
• 2-hour plasma glucose ≥ 200 mg/dL during OGTT
• Random plasma glucose ≥ 200 mg/dL
AND
• Minimum duration of a 30-day trial and failure, contraindication, or intolerance to metformin or another diabetic product (e.g. SGLT-2 Inhibitors, DPP4 Inhibitors, Glinides, Sulfonylureas, Alpha Glucosidase Inhibitors)

Brand liraglutide, Brand Victoza

Prior Authorization (Initial Authorization)

Length of Approval: 1 Year(s)
For diagnosis of Diagnosis of type 2 diabetes mellitus (DM2)

• Patient has a documented diagnosis of type 2 diabetes mellitus as evidenced by medical records documenting one of the following:
• A1C ≥ 6.5%
• Fasting plasma glucose (FPG) ≥ 126 mg/dL
• 2-hour plasma glucose ≥ 200 mg/dL during OGTT
• Random plasma glucose ≥ 200 mg/dL
AND
• Minimum duration of a 30-day trial and failure, contraindication, or intolerance to metformin or another diabetic product (e.g., SGLT-2 Inhibitors, DPP4 Inhibitors, Glinides, Sulfonylureas, Alpha Glucosidase Inhibitors)
AND
• Trial and failure, contraindication, or intolerance to two of the following:
• Mounjaro
• Ozempic or Rybelsus
• Trulicity
• Byetta or Bydureon BCise

Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Generic/Brand liraglutide, Brand Victoza, Mounjaro

Prior Authorization (Reauthorization)

Length of Approval: 1 Year(s)
For diagnosis of Diagnosis of type 2 diabetes mellitus (DM2)

• Documentation of a positive clinical response to therapy (e.g., reduction in HbA1c from baseline)

P & T Revisions

1970-01-01, 2024-11-05

References

1. Byetta Prescribing Information. AstraZeneca Pharmaceuticals LP. Wilmington, DE. December 2022.
2. Victoza Prescribing Information. Novo Nordisk Inc. Plainsboro, NJ. July 2023
3. Trulicity Prescribing Information. Eli Lily and Company. Indianapolis, IN. April 2023
4. Bydureon BCise Prescribing Information. AstraZeneca Pharmaceuticals LP. Wilmington, DE. May 2023
5. Ozempic Prescribing Information. Novo Nordisk Inc. Plainsboro, NJ. September 2023.
6. Mounjaro Prescribing Information. Eli Lily and Company. Indianapolis, IN. September 2023.
7. Rybelsus Prescribing Information. Novo Nordisk Inc. Plainsboro, NJ. January 2024.

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Revision History

• 2024-11-05: New Program

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