OZEMPIC (semaglutide)

OZEMPIC (semaglutide)

SELF ADMINISTRATION

Indications for Prior Authorization:

• Adjunctive therapy to improve glycemic control in type 2 diabetic patients who are compliant with metformin and have not achieved adequate glycemic control
• 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

The following indications do not meet the criteria for use established by the Western Health Advantage Pharmacy and Therapeutics Committee:

• Treatment of Type 1 diabetes
• Treatment of ketoacidosis
• Appetite suppression or treatment of obesity

All of the following must be met as a condition(s) for coverage:

• Diagnosis of Type 2 diabetes confirmed by chart note documentation, AND
• Trial and failure of metformin
• DPP4 (dipeptidyl peptidase-4) inhibitors are not approvable with concurrent administration of GLP-1 (glucagon-like peptide-1) agonists
• Exenatide (Byetta®), Exenatide Extended-Release (Bydureon®, Bydureon BCise®), Liraglutide (Victoza®), Semaglutide (Ozempic®, Rybelsus®), Dulaglutide (Trulicity®) are the preferred agents

Dosing:

• Initial dosage:
  • 0.25 mg once weekly for 4 weeks (the 0.25 mg dose is intended for treatment initiation and is not effective for glycemic control)
• Dosage titration:
  • Increase to 0.5 mg once weekly for at least 4 weeks; if further glycemic control is necessary, increase to a maximum of 1 mg once weekly. 

Approval: 

• 1 year