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“If a pharmacy submits the prescription through the patient’s normal Part D plan instead of the Bridge Program processor, it can come back looking like a denial, even if the patient may actually qualify

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GLP-1 Agonists (Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza) & GIP/GLP-1 Agonist (Mounjaro) Self-Administration – injectable Indications for Prior Authorization: Bydureon BCise: Adjunctive therapy to diet and exercise to improve glycemic control in adults and pediatric patients aged 10 years and older with type 2 diabetes mellitus Byetta: Adjunctive therapy to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus Ozempic: Adjunctive therapy to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus To reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with type 2 diabetes mellitus and established cardiovascular disease Rybelsus: Adjunctive therapy to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus Trulicity: Adjunctive therapy to diet and exercise to improve glycemic control in adults and pediatric patients 10 years of age and older with type 2 diabetes mellitus To reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with type 2 diabetes mellitus who have established cardiovascular disease or multiple cardiovascular risk factors Victoza: Adjunctive therapy to diet and exercise to improve glycemic control in patients 10 years of age and older with type 2 diabetes mellitus To reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with type 2 diabetes mellitus and established cardiovascular disease Mounjaro: Adjunctive therapy to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus Coverage Criteria: For diagnosis of type 2 diabetes mellitus (DM2): Patient has a documented diagnosis of type 2 diabetes mellitus as evidenced by medical records documenting one of the following: A1C ≥ 6.5% Fasting plasma glucose (FPG) ≥ 126 mg/dL 2-hour plasma glucose ≥ 200 mg/dL during OGTT Random plasma glucose ≥ 200 mg/dL, AND Minimum duration of a 30-day trial and failure, contraindication, or intolerance to metformin or another diabetic product Reauthorization Criteria: For diagnosis of type 2 diabetes mellitus (DM2): Documentation of a positive clinical response to therapy (e.g., reduction in HbA1c from baseline) Coverage Duration: Initial: 1 year Reauthorization: 1 year Authorization is not covered for the following: The following indications do not meet the criteria for use established by the Western Health Advantage Pharmacy and Therapeutics Committee: Treatment of type 1 diabetes Treatment of ketoacidosis Appetite suppression or treatment of obesity Additional Information: FDA maximum dose: Bydureon BCise: 2 mg once weekly (3.4 mL per month) Byetta: 10 mcg twice a day (2.4 mL per month) Ozempic: 2 mg once weekly (3 mL per month) Rybelsus: 14 mg once daily (30 tablets per month) Trulicity: 4.5 mg once weekly (2 mL per month) Victoza: 1.8 mg once daily (9 mL per month) Mounjaro: 15 mg once weekly (2 mL per month) Byetta, Mounjaro, Ozempic, Rybelsus: Indicated for 18 years of age or older Bydureon BCise, Trulicity, Victoza: Indicated for 10 years of age or older Treatment guidelines do not support safety and efficacy of GLP-1 agonists when used in combination with a DPP4 inhibitor agent (e.g