Victoza — Blue Cross Blue Shield of Montana

Initial criteria

• Quantity limit criteria met when:
• 1. ONE of the following:
• A. Requested quantity (dose) does NOT exceed program quantity limit OR
• B. Requested quantity exceeds program limit AND one of the following:
• 1. If Mounjaro 2.5 mg is requested for maintenance therapy, BOTH:
• A. Patient cannot use a higher FDA labeled maintenance strength AND
• B. Patient had clinical benefit on lower requested strength from baseline OR
• 2. BOTH: requested agent has no maximum FDA labeled dose and there is support for therapy with higher dose OR
• 3. BOTH: requested dose does NOT exceed FDA max dose and there is support for why dose cannot be achieved with fewer units OR
• 4. BOTH: requested dose exceeds FDA max dose and there is support for therapy with a higher dose AND
• 2. ONE of the following:
• A. Requested fill does NOT exceed program fill limit in past 28 days OR
• B. Requested fill exceeds 28‑day limit AND one of the following:
• 1. Patient is switching to a different strength of same GLP‑1 agent due to inadequate response OR intolerance (higher/lower strength switch) OR
• 2. Patient is switching to a different GLP‑1 agent and has inadequate response OR intolerance or contraindication to prior agent

Approval duration

12 months