Diabetes, GLP-1 Receptor Agonists and GIP Therapies

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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
Current Drug Use Criteria New Drug Evaluation
dulaglutide TRULICITY PEN INJCTR Y PA Document Jan 29, 2015
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  
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