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Victoza — Blue Cross Blue Shield of New Mexico

type 2 diabetes

Preferred products

  • Bydureon BCise
  • Mounjaro
  • Ozempic
  • Trulicity

Initial criteria

  • 1. The patient has a diagnosis of type 2 diabetes AND
  • 2. Diagnosis confirmed by ONE of the following lab tests (chart notes or lab 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 classes of tests are satisfied:
  • 1. ONE of the following (related to semaglutide [Ozempic or Rybelsus]): A. Prescriber states patient is currently treated and stable on requested agent OR B. Tried and inadequate response to semaglutide OR C. Discontinued semaglutide for lack of efficacy or adverse event OR D. Intolerance or hypersensitivity to semaglutide OR E. FDA labeled contraindication to semaglutide OR F. Semaglutide expected ineffective or harmful OR worsening condition OR adherence barrier OR G. Not in best interest of patient based on medical necessity OR H. Tried another prescription drug in the same pharmacologic class as semaglutide and discontinued due to lack of efficacy or adverse event OR I. Requested agent medically necessary and appropriate
  • 2. ONE of the following (related to dulaglutide [Trulicity]): A. Prescriber states patient is currently treated and stable on requested agent OR B. Tried and inadequate response to dulaglutide OR C. Discontinued dulaglutide for lack of efficacy or adverse event OR D. Intolerance or hypersensitivity to dulaglutide OR E. FDA labeled contraindication to dulaglutide OR F. Dulaglutide expected ineffective or harmful OR poses adherence barrier OR G. Not in patient’s best interest OR H. Tried another drug in same pharmacologic class as dulaglutide and discontinued for inefficacy/adverse event OR I. Requested agent medically necessary and appropriate
  • 3. ONE of the following (related to tirzepatide [Mounjaro]): A. Prescriber states patient is currently treated and stable on requested agent OR B. Tried and inadequate response to tirzepatide OR C. Discontinued tirzepatide for inefficacy/adverse event OR D. Intolerance or hypersensitivity to tirzepatide OR E. FDA labeled contraindication to tirzepatide OR F. Expected ineffective/adherence barrier/comorbid condition worsening/adverse reaction/physical or mental harm OR G. Not in best interest of patient OR H. Tried another drug in same class as tirzepatide and discontinued for inefficacy/adverse event OR I. Requested agent medically necessary and appropriate
  • 4. If patient has an FDA labeled indication: ONE of the following: A. Age is within FDA labeling for the requested indication OR B. Support exists for use in patient’s age category for indication AND
  • 5. Patient will NOT use requested agent with any DPP-4 containing agent (see list) AND
  • 6. Patient will NOT use requested agent with another GLP-1 receptor agonist AND
  • 7. Patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

  • 1. Patient previously approved for therapy with an agent targeted in this policy within the past 12 months AND
  • 2. ONE of the following: A. Requested agent is a preferred GLP-1 or GLP-1/GIP OR B. Agent is a non-preferred GLP-1 or GLP-1/GIP and TWO of the same sets of criteria for semaglutide, dulaglutide, and tirzepatide as described in the initial evaluation apply

Approval duration

12 months