Liraglutide (Victoza®)


Indications for Prior Authorization:
  • Adjunctive therapy to diet and exercise to improve glycemic control in patients 10 years of age and older with type 2 diabetes mellitus
  • To reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with type 2 diabetes mellitus and established cardiovascular disease
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
  • Type 2 diabetes mellitus:
    • Initial dosage:
      • 0.6 mg subcutaneously per day for 1 week.
    • 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
  • 1 year

Last review date: July 15, 2020

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