Albiglutide (Tanzeum®), Dulaglutide (Trulicity®), Exenatide (Byetta®), exenatide extended release (Bydureon®),  and liraglutide (Victoza®)


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

  • Current A1c greater than 7 but less than 10 while compliant on oral therapy must be submitted for approval

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

  • Failure, as defined as an HbA1c > 7%, intolerance or contraindication to metformin at maximum effective therapeutic dose of 1,500 mg/day or maximum tolerated does unless contraindicated.  Unless contraindicated, member must currently adhere to maximal tolerated dose of metformin

    • An A1c level must be taken after a minimum of 3 months since last metformin dose change with confirmation in the pharmacy claims adjudication history of patient compliance with the treatment regimen

  • Concurrent administration with any dipeptidyl peptidase-4 inhibitor is not approvable

  • Albiglutide (Tanzeum) is the preferred agent

albiglutide (Tanzeum)


  • Usual dosing:  30 mg SubQ once weekly.

  • May increase to 50 mg SubQ once weekly for inadequate glycemic response

dulaglutide (Trulicity)


  • 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

exenatide (Byetta®)


  • Initiate at 5 mcg SubQ twice a day 60 minutes prior to morning and evening meals. If an inadequate response, then dose may be increased to 10 mcg twice a day after one month

exenatide extended release (Bydureon®)


  • Inject 2 mg SubQ every week

liraglutide (Victoza®)


  • Type 2 diabetes mellitus:
  • Initial dosage:
    • 0.6 mg subcutaneously per day for 1 week.1
  • Dosage titration:
    • After 1 week at 0.6 mg/day subcutaneously, the dose should be increased to 1.2 mg. If the 1.2 mg dose does not result in acceptable glycemic control, the dose can be increased to 1.8 mg


Last review date: July 21, 2016

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