Skip to content
The Policy VaultThe Policy Vault

Victoza — Blue Cross Blue Shield of Texas

type 2 diabetes

Preferred products

  • Bydureon BCise
  • Mounjaro
  • Ozempic
  • Trulicity

Initial criteria

  • The patient has a diagnosis of type 2 diabetes
  • The patient’s diagnosis has been confirmed by ONE of the following lab tests: 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
  • 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:
  • 1. ONE of the following regarding semaglutide (Ozempic OR Rybelsus): current stable use; inadequate response; discontinued for lack of efficacy, adverse event, intolerance, hypersensitivity, or contraindication; expected ineffective; not in best interest; tried another agent with same mechanism discontinued; requested agent medically necessary
  • 2. ONE of the following regarding dulaglutide (Trulicity): current stable use; inadequate response; discontinued for lack of efficacy, adverse event, intolerance, hypersensitivity, or contraindication; expected ineffective; not in best interest; tried another agent with same mechanism discontinued; requested agent medically necessary
  • 3. ONE of the following regarding tirzepatide (Mounjaro): current stable use; inadequate response; discontinued for lack of efficacy, adverse event, intolerance, hypersensitivity, or contraindication; expected ineffective; not in best interest; tried another agent with same mechanism discontinued; requested agent medically necessary
  • If patient has an FDA labeled indication, age is within labeling or supported for the indication
  • The patient will not use the requested agent in combination with a DPP-4 inhibitor
  • The patient will not use the requested agent in combination with another GLP-1 receptor agonist
  • The patient does not have any FDA labeled contraindications to the requested agent

Reauthorization criteria

  • The patient has been previously approved for therapy with an agent targeted in this policy within the past 12 months
  • 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:
  • 1. ONE of the following regarding semaglutide (Ozempic OR Rybelsus): current stable use; inadequate response; discontinued for lack of efficacy, adverse event, intolerance, hypersensitivity, or contraindication; expected ineffective; not in best interest; tried another agent with same mechanism discontinued; requested agent medically necessary

Approval duration

12 months