Insulin Degludec and Liraglutide (Xultophy®)


Xultophy is the preferred agent

All of the following must be met as a condition for coverage:
  • Diagnosis of Type 2 diabetes
  • Current A1c greater than 7 but less than 10 while compliant on oral therapy and Victoza
  • Failure, intolerance or contraindication to metformin at maximum effective therapeutic dose of 1,500 mg/day or maximum tolerated dose 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 or any other glucagon-like peptide-1 (GLP-1) agonist is not approvable
The following indications do not meet the criteria for use established by the Western Health Advantage Pharmacy and Therapeutic Committee:
  • Treatment of Type 1 diabetes
  • Treatment of ketoacidosis
  • Appetite suppression or treatment of obesity

Last review date: November 13, 2018

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