semaglutide (Ozempic®)


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
  • Exenatide (Byetta), Exenatide Extended-Release (Bydureon, Bydureon BCise) and Liraglutide (Victoza) are the preferred agents


  • Initial dosage:
    • 0.25 mg once weekly for 4 weeks.  
  • Dosage titration:
    • Increase to 0.5 mg once weekly for at least 4 weeks; if further glycemic control is necessary, increase to a maximum of 1mg once weekly. 

Last review date: November 15, 2018

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