Skip to content
The Policy VaultThe Policy Vault

liraglutide — Blue Cross Blue Shield of Illinois

type 2 diabetes

Preferred products

  • Bydureon BCise
  • Mounjaro
  • Ozempic
  • Trulicity

Initial criteria

  • 1. The patient has a diagnosis of type 2 diabetes AND
  • 2. The patient’s diagnosis has been confirmed by ONE of the following lab tests [chart notes or a copy of lab test results required]: A. A1C ≥ 6.5% OR B. Fasting plasma glucose ≥ 126 mg/dL OR C. 2-hour plasma glucose ≥ 200 mg/dL during OGTT OR D. Random plasma glucose ≥ 200 mg/dL with symptoms of hyperglycemia AND
  • 3. ONE of the following: A. The requested agent is a preferred GLP-1 or GLP-1/GIP receptor agonist OR B. The agent is a non-preferred GLP-1 or GLP-1/GIP receptor agonist and TWO of the following: (1) ONE of multiple specific conditions regarding treatment or intolerance with semaglutide (Ozempic, Rybelsus), dulaglutide (Trulicity), or tirzepatide (Mounjaro); (2) another set of comparable conditions as listed in the policy
  • 4. If the patient has an FDA labeled indication, then ONE of the following: A. The patient’s age is within FDA labeling for the requested indication for the requested agent OR B. There is support for using the requested agent for the patient’s age for the requested indication
  • 5. The patient will NOT be using the requested agent in combination with a DPP-4 containing agent (e.g., Januvia, Janumet, Janumet XR, Jentadueto, Jentadueto XR, Kazano, Kombiglyze XR, Nesina, Onglyza, Oseni, Tradjenta, Zituvio, Zituvimet)
  • 6. The patient will NOT be using the requested agent in combination with another GLP-1 receptor agonist agent (e.g., Saxenda, Wegovy, Zepbound, Bydureon, Byetta, Exenatide, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza)
  • 7. The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

  • 1. The patient has been previously approved for therapy with an agent targeted in this policy (i.e., Bydureon BCise, Mounjaro, Ozempic, Rybelsus, Trulicity, Byetta, Exenatide, Victoza, liraglutide) through the plan’s prior authorization process in the past 12 months AND
  • 2. ONE of the following: A. The requested agent is a preferred GLP-1 or GLP-1/GIP OR B. The agent is a non-preferred GLP-1 or GLP-1/GIP and TWO of the following: same step options regarding trial/failure or intolerance with semaglutide (Ozempic, Rybelsus), dulaglutide (Trulicity), or tirzepatide (Mounjaro)

Approval duration

12 months