Byetta — Blue Cross Blue Shield of Alabama

Preferred products

• Ozempic
• Rybelsus
• Trulicity
• Mounjaro
• Bydureon BCise

Initial criteria

• - Patient has a diagnosis of type 2 diabetes AND diagnosis confirmed by lab test (e.g., A1C ≥ 6.5%) (lab results or medical records required)
• - ONE of the following: • Requested agent eligible for continuation of therapy AND ONE of the following: - Agents eligible for continuation: Ozempic, Rybelsus, Trulicity, Mounjaro, Bydureon BCise - Patient has been treated with a preferred agent within past 90 days (samples not acceptable) - Prescriber states patient has been treated with a preferred agent within past 90 days and is at risk if therapy with preferred agent discontinued • ALL of the following: - ONE of the following: • Tried and had inadequate response to metformin or insulin • Intolerance or hypersensitivity to metformin or insulin • FDA labeled contraindication to BOTH metformin AND insulin - OR BOTH of the following: • Patient has established cardiovascular disease (e.g., myocardial infarction, stroke, transient ischemic attack, unstable angina, amputation, symptomatic/asymptomatic CAD) or multiple cardiovascular risk factors (e.g., hypertension, dyslipidemia, family history of CVD, smoking) • Requested agent used to reduce risk of major adverse cardiovascular events (e.g., CV death, nonfatal MI or stroke) - OR BOTH of the following: • Patient has chronic kidney disease (CKD) • Requested agent will be used to reduce risk of sustained eGFR decline, end-stage kidney disease, and cardiovascular death - ONE of the following: • Requested agent is a preferred GLP-1 or GLP-1/GIP receptor agonist • Requested agent is a non-preferred GLP-1 receptor agonist AND TWO of the following: - Tried and inadequate response after ≥90-day trial, intolerance, hypersensitivity, or contraindication to semaglutide (Ozempic OR Rybelsus) - Tried and inadequate response after ≥90-day trial, intolerance, hypersensitivity, or contraindication to dulaglutide (Trulicity) - Tried and inadequate response after ≥90-day trial, intolerance, hypersensitivity, or contraindication to tirzepatide (Mounjaro) - If patient has FDA-labeled indication, ONE of the following: • Age within FDA labeling for requested indication/agent • Support for use in patient’s age group for indication - Patient will NOT use requested agent in combination with DPP-4 agent (e.g., Januvia, Janumet, Jentadueto, Kazano, Kombiglyze XR, Nesina, Onglyza, Oseni, Tradjenta, Zituvio, Zituvimet) - Patient will NOT use requested agent in combination with another GLP-1 receptor agonist (e.g., Saxenda, Wegovy, Zepbound, Bydureon, Byetta, Exenatide, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza) - Patient does NOT have any FDA labeled contraindications to requested agent

Reauthorization criteria

• Continuation requests follow same criteria for continuation eligible agents.

Approval duration

12 months