RYBELSUS (semaglutide)

RYBELSUS (semaglutide)

SELF ADMINISTRATION

Indications for Prior Authorization:

• Adjunctive therapy to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus

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

Dosing:

• Initial dosage:
  • 3 mg once daily for 30 days.  The 3 mg dose is intended for treatment initiation and is not effective for glycemic control.  
• Dosage titration:
  • After 30 days on the 3 mg dose, increase the dose to 7 mg once daily.
  • Dose may be increased to 14 mg once daily if additional glycemic control is needed after at least 30 days on the 7 mg dose.
  • Taking two 7 mg Rybelsus® tablets to achieve a 14 mg dose is not recommended, and thus is not approvable under prior authorization. 
• Switching patients between Ozempic® and Rybelsus®
  • Patients treated with Rybelsus® 14 mg daily can be transitioned to Ozempic® subcutaneous injection 0.5 mg once weekly.  Patients can start Ozempic® the day after their last dose of Rybelsus®.
  • Patients treated with once weekly Ozempic® 0.5 mg subcutaneous injection can be transitioned to Rybelsus® 7 or 14 mg.  Patients can start Rybelsus® up to 7 days after their last injection of Ozempic®.
  • There is no equivalent dose of Rybelsus® for Ozempic® 1 mg.

Approval: 

• 1 year