Byetta — Medical Mutual

Initial criteria

• Diagnosis of type 2 diabetes confirmed by ONE of the following: Hemoglobin A1c (HbA1c) ≥ 6.5% OR Fasting plasma glucose (FPG) ≥ 126 mg/dL OR 2-hour plasma glucose (2-h PG) ≥ 200 mg/dL
• AND Patient meets ONE of the following: If request is for Adlyxin, Byetta, exenatide (generic to Byetta), Mounjaro, Ozempic, or Rybelsus: age ≥ 18 years; OR If request is for Bydureon BCise, Trulicity, Victoza, or liraglutide: age ≥ 10 years

Approval duration

180 days initial, 365 days extended