Victoza (liraglutide) — United Healthcare

Type 2 diabetes mellitus

Initial criteria

Submission of medical records (e.g., chart notes) confirming diagnosis of type 2 diabetes mellitus as evidenced by one of the following laboratory values:
– A1C ≥ 6.5%
– Fasting plasma glucose (FPG) ≥ 126 mg/dL
– 2-hour plasma glucose (PG) ≥ 200 mg/dL during oral glucose tolerance test
– Random plasma glucose ≥ 200 mg/dL in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis
OR
For patients requiring ongoing treatment for type 2 diabetes mellitus (diagnosed > 2 years ago), submission of medical records confirming diagnosis of type 2 diabetes mellitus
Medication not prescribed for weight loss

12 months