TRULICITY (dulaglutide)

TRULICITY (dulaglutide)

SELF-ADMINISTRATION - subcutaneous injection

Diagnoses considered for coverage:

• Type 2 Diabetes Mellitus (DM2) - adjunct to diet and exercise to improve glycemic control in adults with DM2.
• Type 2 Diabetes Mellitus (DM2) - to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with DM2 who have established cardiovascular disease or multiple cardiovascular risk factors.

Coverage Criteria:

To improve glycemic control in adults with type 2 diabetes mellitus (DM2):

• All of the following:
  • Diagnosis of DM2 is confirmed by medical records; AND
  • Patient has experienced an inadequate response, contraindication, or intolerable side effects to metformin; AND
  • Patient will not use a dipeptidyl peptidase-4 (DPP-4) inhibitor agent in combination with Trulicity.

Dosing:

• Initial Dosing:  0.75 mg subcutaneous injection once weekly.
• Increase the dose to 1.5 mg subcutaneous injection once weekly for additional glycemic control as needed.
• Maximum dose:  4.5 mg subcutaneous injection once weekly.

Coverage Duration: 

• Initial and reauthorization: 1 year.

Authorization is not covered for the following:

The following conditions, and other uses of this drug for indications not listed in this policy, do not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

• Treatment of type 1 diabetes (DM1)
• Treatment of ketoacidosis
• Appetite suppression or treatment of obesity

Additional Information:

• DPP-4 inhibitor agents include alogliptan [Nesina], linagliptin [Tradjenta], sitagliptin [Januvia], and saxagliptan [Onglyza].

Policy Updates

• 07/16/2021 - added indication for DM2 with established cardiovascular disease or multiple cardiovascular risk factors; updated maximum allowable dose; updated policy format.