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tirzepatide (Mounjaro) — Blue Cross Blue Shield of Montana

Type 2 diabetes mellitus

Preferred products

  • dulaglutide (Trulicity)
  • tirzepatide (Mounjaro)

Initial criteria

  • 1. ONE of the following for each target agent sequence:
  • A. The prescriber states the patient is currently being treated with the requested agent AND the patient is currently stable on the requested agent OR
  • B. The patient has tried and had an inadequate response to the preferred agent dulaglutide (Trulicity) OR
  • C. The preferred agent dulaglutide (Trulicity) was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event OR
  • D. The patient has an intolerance or hypersensitivity to dulaglutide (Trulicity) OR
  • E. The patient has an FDA labeled contraindication to dulaglutide (Trulicity) OR
  • F. dulaglutide (Trulicity) is expected to be ineffective based on clinical characteristics or would cause adverse outcome (adherence barrier, worsen comorbidity, reduce functional ability, cause harm) OR
  • G. dulaglutide (Trulicity) is not in the best interest of the patient based on medical necessity OR
  • H. The patient has tried another drug with same mechanism as dulaglutide (Trulicity) and it was discontinued due to lack of efficacy or adverse event OR
  • I. The requested agent is medically necessary and appropriate
  • For tirzepatide (Mounjaro) same criteria (A–I) relative to tirzepatide
  • 3. The patient has had clinical benefit with a targeted GLP-1 agent (Bydureon BCise, Mounjaro, Ozempic, Rybelsus, Trulicity, Byetta, Exenatide, Victoza, liraglutide)
  • 4. The patient will NOT use the requested agent with a DPP-4 inhibitor (e.g., Januvia, Janumet, Janumet XR, Jentadueto, Jentadueto XR, Kazano, Kombiglyze XR, Nesina, Onglyza, Oseni, Tradjenta, Zituvio, Zituvimet)
  • 5. The patient will NOT use the requested agent with another GLP-1 receptor agonist (e.g., Saxenda, Wegovy, Zepbound, Bydureon, Byetta, Exenatide, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza)
  • 6. The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months