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Trulicity — Blue Cross Blue Shield of Kansas

type 2 diabetes

Preferred products

  • Bydureon BCise

Initial criteria

  • Diagnosis of type 2 diabetes confirmed by lab tests (e.g., A1C ≥ 6.5%)
  • ONE of the following: (A) Requested agent eligible for continuation of therapy (Ozempic, Rybelsus, Trulicity, Mounjaro, Bydureon BCise) AND patient has been treated with a preferred agent within past 90 days or prescriber states treatment within past 90 days and is at risk if discontinued OR (B) ALL of the following:
  • - ONE of the following:
  • • Patient has tried and had inadequate response to metformin or insulin OR
  • • Patient has intolerance or hypersensitivity to metformin or insulin OR
  • • Patient has contraindication to BOTH metformin AND insulin OR
  • • BOTH of the following: (1) Patient has established cardiovascular disease or multiple cardiovascular risk factors AND (2) requested agent will be used to reduce risk of major adverse cardiovascular events OR
  • • BOTH of the following: (1) Patient has chronic kidney disease AND (2) 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 OR
  • • Agent is non-preferred AND TWO of the following: (1) Patient has tried and failed, intolerant, hypersensitive, or contraindicated to semaglutide (Ozempic or Rybelsus) for ≥90 days; (2) tried and failed, intolerant, hypersensitive, or contraindicated to dulaglutide (Trulicity) for ≥90 days; (3) tried and failed, intolerant, hypersensitive, or contraindicated to tirzepatide (Mounjaro) for ≥90 days
  • If FDA labeled indication, patient’s age is within FDA labeling or supported for using requested agent at that age
  • Patient will NOT use requested agent with DPP-4–containing agent (e.g., Brynovin, Januvia, Janumet, Janumet XR, Jentadueto, Jentadueto XR, 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

Approval duration

12 months