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Byetta — Blue Cross Blue Shield of Montana

type 2 diabetes

Preferred products

  • Bydureon BCise
  • Mounjaro
  • Ozempic
  • Trulicity

Initial criteria

  • The patient has a diagnosis of type 2 diabetes AND confirmed by A1C ≥ 6.5% OR fasting plasma glucose ≥ 126 mg/dL OR 2-hour plasma glucose ≥ 200 mg/dL during OGTT OR random plasma glucose ≥ 200 mg/dL with symptoms of hyperglycemia AND
  • The requested agent is a preferred GLP-1 or GLP-1/GIP receptor agonist OR if it is a non-preferred agent (Byetta, Exenatide, Victoza, Rybelsus) then TWO of the following conditions are met:
  • 1. ONE of the following regarding semaglutide (Ozempic OR Rybelsus): currently stable on requested agent OR inadequate response, discontinued due to adverse events, intolerance/hypersensitivity, contraindication, expected inefficacy, not in best interest/medical necessity, or prior class-level trial discontinued OR medically necessary and appropriate for patient;
  • 2. ONE of the following regarding dulaglutide (Trulicity): currently stable on requested agent OR inadequate response, discontinued due to adverse events, intolerance/hypersensitivity, contraindication, expected inefficacy, not in best interest/medical necessity, or prior class-level trial discontinued OR medically necessary and appropriate for patient;
  • 3. ONE of the following regarding tirzepatide (Mounjaro): currently stable on requested agent OR inadequate response, discontinued due to adverse events, intolerance/hypersensitivity, contraindication, expected inefficacy, not in best interest/medical necessity, or prior class-level trial discontinued OR medically necessary and appropriate for patient;
  • If patient has an FDA labeled indication, age within labeling OR evidence supporting use at patient’s age AND
  • Patient will NOT use with a DPP-4 agent (e.g., Januvia, Janumet, etc.) AND
  • Patient will NOT use with another GLP-1 receptor agonist AND
  • Patient does not have any FDA labeled contraindications to the requested agent

Reauthorization criteria

  • Patient previously approved for therapy with a GLP-1 or GLP-1/GIP agent in this policy in past 12 months AND
  • The requested agent is preferred OR if non-preferred then TWO of the following conditions are met:
  • 1. Regarding semaglutide (Ozempic or Rybelsus): stability on therapy OR inadequate response, discontinued due to adverse events, intolerance/hypersensitivity, contraindication, expected inefficacy, not in best interest, prior class-level trial discontinued, or medically necessary;
  • 2. Regarding dulaglutide (Trulicity): stability on therapy OR inadequate response, discontinued due to adverse events, intolerance/hypersensitivity, contraindication, expected inefficacy, not in best interest, prior class-level trial discontinued, or medically necessary;
  • 3. Regarding tirzepatide (Mounjaro): stability on therapy OR inadequate response, discontinued due to adverse events, intolerance/hypersensitivity, contraindication, expected inefficacy, not in best interest, prior class-level trial discontinued, or medically necessary

Approval duration

12 months