Dulaglutide (Trulicity®)

SELF ADMINISTRATION

Indications for Prior Authorization:
  • Adjunctive therapy to improve glycemic control in type 2 diabetic patients who are compliant with metformin and have not achieved adequate glycemic control
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
All of the following must be met as a condition(s) for coverage:
  • Diagnosis of Type 2 diabetes confirmed by chart note documentation, AND
  • Trial and failure of metformin
  • DPP4 (dipeptidyl peptidase-4) inhibitors are not approvable with concurrent administration of GLP-1 (glucagon-like peptide-1) agonists
  • Exenatide (Byetta®), Exenatide Extended-Release (Bydureon®, Bydureon BCise®), Liraglutide (Victoza®), Semaglutide (Ozempic®, Rybelsus®), Dulaglutide (Trulicity®) are the preferred agents
Dosing:
  • Initial Dosing:  0.75 mg SubQ once weekly
  • May increase to 1.5 mg once weekly if inadequate glycemic response
  • Maximum dose:  1.5 mg once weekly
Approval: 
  • 1 year

 

Last review date: April 22, 2020

WHA is closely monitoring the Coronavirus Disease 2019 (COVID-19). Learn more about COVID-19.