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Basal insulin and GLP-1 receptor agonist combination

Drugs - Soliqua (insulin glargine/lixisenatide) [Sanofi]; Xultophy (insulin degludec/liraglutide) [Novo Nordisk]

June 2017

Therapeutic area - Hypoglycemics/Incretin mimetics/enhancers

Approval criteria

  • Patient is 18 years of age or older AND
  • Patient must have a diagnosis of type 2 diabetes mellitus AND
  • Patient has not achieved adequate glycemic control on at least two of the following used separately or simultaneously:
    • metformin (alone or in combination with a sulfonylurea or a thiazolidinedione) 
    • a sulfonylurea (alone or in combination with metformin) 
    • an oral DPP IV inhibitor (eg, Januvia, Onglyza)
    AND
  • Patient must have tried and failed a preferred long-acting insulin (Lantus OR Levemir) AND a preferred GLP-1 receptor agonist (Byetta)

Denial criteria

Patient has one of the following conditions:

  • Type 1 diabetes mellitus
  • Diabetic ketoacidosis
  • Pancreatitis
  • Gastroparesis
  • End stage renal disease (eGFR < 15 mL/min/1.73 m2)

Quantity limits

  • Soliqua: 1 carton of 5 pens (15mL) per 25 days
  • Xultophy: 1 carton of 5 pens (15mL) per 30 days

Background information

Combination of basal insulin and GLP-1 receptor agonists are indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus inadequately controlled on basal insulin or GLP-1 receptor agonist. They are not recommended as first-line therapy for patients inadequately controlled on diet and exercise.

Questions?

MHCP Provider Call Center 651-431-2700 or 800-366-5411

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