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GLP-1 receptor agonists

November 2018

Therapeutic area - Hypoglycemics

Preferred
Byetta
Bydureon Vial
Victoza

Nonpreferred
Adlyxin
Bydureon BCise
Bydureon Pen
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:
  • Patient has had an adequate adherent trial and failure of (or contraindication to) three 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 Vial 4 trays
Victoza 2-Pak 6mL
Victoza 3-Pak 9mL


Nonpreferred Quantity Limits
Adlyxin (10 mcg and 20 mcg per dose) 6mL
Bydureon BCise 3.4mL
Bydureon Pen 4 pens
Ozempic 1-Pen 1.5mL
Ozempic 2-Pen 1.5mL
Trulicity 2mL

Questions?

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

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