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

July 2018

Therapeutic area - Hypoglycemics/Incretin mimetics and synthemic amylin

Preferred
Byetta
Bydureon Vial
Victoza

Nonpreferred
Adlyxin
Bydureon BCise
Bydureon Pen
Ozempic
Trulicity

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)
    • a preferred SGLT2 inhibitor AND
  • Patient has had an adequate adherent trial and failure of (or contraindication to) at least three preferred drugs 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 (5mcg and 10 mcg per dose) 2.4mL
Bydureon Vial 4 trays
Victoza 2-Pak 6mL
Victoza 3-Pak 9mL


Nonpreferred Quantity Limits
Adyxin (50mcg and 100 mcg per mL) 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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