XULTOPHY (insulin degludec and liraglutide)
SELF ADMINISTRATION
Xultophy is the preferred agent
All of the following must be met as a condition for coverage:
- Diagnosis of Type 2 diabetes, AND
- Current A1c greater than 7 but less than 10 while compliant on oral therapy and Victoza, AND
- Failure, intolerance, or contraindication to metformin at the 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, AND
- An A1c Level must be taken after a minimum of 3 months since the 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: December 1, 2023