Exenatide — Blue Cross Blue Shield of Oklahoma

Type 2 diabetes

Preferred products

The patient has a diagnosis of type 2 diabetes AND
The diagnosis confirmed by ONE of the following laboratory results (documentation required): A1C ≥ 6.5% OR Fasting plasma glucose ≥ 126 mg/dL OR 2-hour OGTT plasma glucose ≥ 200 mg/dL OR Random plasma glucose ≥ 200 mg/dL with hyperglycemia symptoms AND
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/GLP-1 GIP agonist and TWO of the following conditions apply: (1) ONE of the subpoints A–I regarding semaglutide (Ozempic or Rybelsus) treatment adequacy/intolerance, or medical necessity AND (2) ONE of the subpoints A–I regarding dulaglutide (Trulicity) treatment adequacy/intolerance, or medical necessity AND (3) ONE of the subpoints A–I regarding tirzepatide (Mounjaro) treatment adequacy/intolerance, or medical necessity
If the patient has an FDA-labeled indication, age must be within labeling or medically supported for that age AND
The patient will NOT use the requested agent in combination with a DPP-4 containing agent AND the patient will NOT use the requested agent in combination with another GLP-1 receptor agonist AND
The patient does NOT have any FDA labeled contraindications to the requested agent

The patient has been previously approved for therapy with a targeted GLP-1 (Bydureon BCise, Mounjaro, Ozempic, Rybelsus, Trulicity, Byetta, Exenatide, Victoza, liraglutide) through the plan’s PA process within the past 12 months AND
ONE of the following: (A) The requested agent is a preferred GLP-1 or GLP-1/GIP OR (B) The agent is a non-preferred GLP-1 or GLP-1/GIP receptor agonist and TWO of the following apply: (1) Criteria similar to those in initial (A–I) regarding semaglutide (Ozempic/Rybelsus) and (2) Criteria similar to those in initial (A–I) regarding dulaglutide (Trulicity) and others as medically necessary

12 months