GLP-1 receptor agonists

April 2019

Therapeutic area - Hypoglycemics

Preferred
Byetta
Bydureon Pen
Victoza

Nonpreferred
Adlyxin
Bydureon BCise
Ozempic
Trulicity

Combination GLP1-insulin products (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)
  • a preferred DPP IV inhibitor
  • a preferred SGLT2 inhibitor AND
• Patient has had an adequate adherent trial and failure of (or contraindication to) two preferred GLP-1 products AND
• Patient must not have any of the following:
  • Type 1 diabetes mellitus
  • Diabetic ketoacidosis
  • Pancreatitis
  • Gastroparesis
  • End stage renal disease (eGFR < 15 mL/min/1.73 m2)
  • Multiple endocrine neoplasia syndrome type 2 (MEN 2)
  • Personal or family history of medullary thyroid carcinoma (MTC)

Quantity limits

Preferred	Quantity Limits
Byetta (5 mcg and 10 mcg per dose)	2.4mL
Bydureon Pen	4 pens
Victoza 2-Pak	6mL
Victoza 3-Pak	9mL

Nonpreferred	Quantity Limits
Adlyxin (10 mcg and 20 mcg per dose)	6mL
Bydureon BCise	3.4mL
Ozempic 1-Pen	1.5mL
Ozempic 2-Pen	3mL
Trulicity	2mL

Questions?

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