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GLP-1 (Glucagon-like peptide-1) receptor agonists

Byetta (exenetide) [AstraZeneca]
Adlyxin (lixisenatide) [Sanofi],
Bydureon (exenetide extended release suspension) [AstraZeneca],
Tanzeum (abiglutide) [GlaxoSmithKline],
Trulicity (dulaglutide) [Eli Lilly and Company],
Victoza (liraglutide) [Novo Nordisk]

June 2017

Therapeutic area - Hypoglycemics/Incretin mimetics and synthemic amylin



Soliqua and Xultophy are under separate PA criteria sheet.  See PA criteria sheet, “Basal insulin and GLP-1-receptor agonist combination”

Approval criteria for nonpreferred drugs:

  • 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 has been tried on Byetta (Exenatide) and was non-adherent due to the frequency of injections, did not achieve adequate glycemic control despite adherence to Byetta or did not develop tolerance to nausea while adhering to Byetta for 3-4 weeks of therapy

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

Preferred Quantity Limits (mL or pen)
Byetta (5mcg and 10 mcg per dose) 2.4mL
Nonpreferred Quantity Limits (mL or pen)
Adyxin (50mcg and 100 mcg per mL) 6mL
Bydureon 4 pens
Tanzeum (30mg and 50mg per dose) 4 pens
Trulicity 2mL
Victoza 2-Pak 6mL
Victoza 3-Pak 9mL


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

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