Diabetes, GLP-1 Receptor Agonists and GIP Therapies
PDL Reference Documents
Drug Use Review Documents
Newsletters
PDL Status Values
Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the
Non-Preferred Drugs in Select PDL Classes prior authorization criteria.
New drugs will be listed as N until reviewed by the P&T Committee and are subject to the
New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.
To request a Prior Authorization, please use this form.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | New Drug Evaluation & Updates |
|---|---|---|---|---|---|
| dulaglutide | TRULICITY | PEN INJCTR | Y | PA Document | Jan 29, 2015 |
| exenatide | EXENATIDE | PEN INJCTR | Y | PA Document | |
| exenatide | BYETTA | PEN INJCTR | Y | PA Document | Apr 26, 2012 |
| liraglutide | VICTOZA 2-PAK | PEN INJCTR | Y | PA Document | |
| liraglutide | VICTOZA 3-PAK | PEN INJCTR | Y | PA Document | |
| liraglutide | LIRAGLUTIDE | PEN INJCTR | Y | PA Document | |
| exenatide microspheres | BYDUREON BCISE | AUTO INJCT | N | PA Document | |
| semaglutide | OZEMPIC | PEN INJCTR | N | PA Document | |
| semaglutide | RYBELSUS | TABLET | N | PA Document | |
| tirzepatide | MOUNJARO | PEN INJCTR | N | PA Document |