Diabetes, GLP-1 Receptor Agonists and GIP Therapies
PDL Reference Documents
Drug Use Review Documents
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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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 00002143301 | TRULICITY | dulaglutide | PEN INJCTR | 0.75 mg/0.5 mL | Y | Y | PA Document |
| 00002143361 | TRULICITY | dulaglutide | PEN INJCTR | 0.75 mg/0.5 mL | Y | Y | PA Document |
| 00002143380 | TRULICITY | dulaglutide | PEN INJCTR | 0.75 mg/0.5 mL | Y | Y | PA Document |
| 00002143401 | TRULICITY | dulaglutide | PEN INJCTR | 1.5 mg/0.5 mL | Y | Y | PA Document |
| 00002143480 | TRULICITY | dulaglutide | PEN INJCTR | 1.5 mg/0.5 mL | Y | Y | PA Document |
| 00002223601 | TRULICITY | dulaglutide | PEN INJCTR | 3 mg/0.5 mL | Y | Y | PA Document |
| 00002223680 | TRULICITY | dulaglutide | PEN INJCTR | 3 mg/0.5 mL | Y | Y | PA Document |
| 00002318201 | TRULICITY | dulaglutide | PEN INJCTR | 4.5 mg/0.5 mL | Y | Y | PA Document |
| 00002318280 | TRULICITY | dulaglutide | PEN INJCTR | 4.5 mg/0.5 mL | Y | Y | PA Document |
| 00310652401 | BYETTA | exenatide | PEN INJCTR | 10 mcg/0.04 mL per dose (250 mcg/mL) 2.4 mL | Y | Y | PA Document |
| 70121168601 | EXENATIDE | exenatide | PEN INJCTR | 10 mcg/0.04 mL per dose (250 mcg/mL) 2.4 mL | Y | Y | PA Document |
| 00310651201 | BYETTA | exenatide | PEN INJCTR | 5 mcg/0.02 mL per dose (250 mcg/mL) 1.2 mL | Y | Y | PA Document |
| 70121168501 | EXENATIDE | exenatide | PEN INJCTR | 5 mcg/0.02 mL per dose (250 mcg/mL) 1.2 mL | Y | Y | PA Document |
| 00310654001 | BYDUREON BCISE | exenatide microspheres | AUTO INJCT | 2 mg/0.85 mL | N | Y | PA Document |
| 00310654004 | BYDUREON BCISE | exenatide microspheres | AUTO INJCT | 2 mg/0.85 mL | N | Y | PA Document |
| 00310654085 | BYDUREON BCISE | exenatide microspheres | AUTO INJCT | 2 mg/0.85 mL | N | Y | PA Document |
| 00143914401 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 0.6 mg/0.1 mL (18 mg/3 mL) | Y | Y | PA Document |
| 00143914402 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 0.6 mg/0.1 mL (18 mg/3 mL) | Y | Y | PA Document |
| 00143914403 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 0.6 mg/0.1 mL (18 mg/3 mL) | Y | Y | PA Document |
| 00480366719 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 0.6 mg/0.1 mL (18 mg/3 mL) | Y | Y | PA Document |
| 00480366720 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 0.6 mg/0.1 mL (18 mg/3 mL) | Y | Y | PA Document |
| 00480366722 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 0.6 mg/0.1 mL (18 mg/3 mL) | Y | Y | PA Document |
| 70748034601 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 0.6 mg/0.1 mL (18 mg/3 mL) | Y | Y | PA Document |
| 70748034602 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 0.6 mg/0.1 mL (18 mg/3 mL) | Y | Y | PA Document |
| 70748034603 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 0.6 mg/0.1 mL (18 mg/3 mL) | Y | Y | PA Document |
| 71288056383 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 0.6 mg/0.1 mL (18 mg/3 mL) | Y | Y | PA Document |
| 71288056384 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 0.6 mg/0.1 mL (18 mg/3 mL) | Y | Y | PA Document |
| 71288056385 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 0.6 mg/0.1 mL (18 mg/3 mL) | Y | Y | PA Document |
| 00169406012 | VICTOZA 2-PAK | liraglutide | PEN INJCTR | 0.6 mg/0.1 mL (18 mg/3 mL) | Y | Y | PA Document |
| 00169406013 | VICTOZA 3-PAK | liraglutide | PEN INJCTR | 0.6 mg/0.1 mL (18 mg/3 mL) | Y | Y | PA Document |
| 00480725019 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 3 mg/0.5 mL (18 mg/3 mL) | N | Y | PA Document |
| 00480725046 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 3 mg/0.5 mL (18 mg/3 mL) | N | Y | PA Document |
| 00169418103 | OZEMPIC | semaglutide | PEN INJCTR | 0.25 mg or 0.5 mg dose (2 mg/3 mL) | N | Y | PA Document |
| 00169418113 | OZEMPIC | semaglutide | PEN INJCTR | 0.25 mg or 0.5 mg dose (2 mg/3 mL) | N | Y | PA Document |
| 00169418197 | OZEMPIC | semaglutide | PEN INJCTR | 0.25 mg or 0.5 mg dose (2 mg/3 mL) | N | Y | PA Document |
| 00169413001 | OZEMPIC | semaglutide | PEN INJCTR | 1 mg/0.75 mL (4 mg/3 mL) | N | Y | PA Document |
| 00169413013 | OZEMPIC | semaglutide | PEN INJCTR | 1 mg/0.75 mL (4 mg/3 mL) | N | Y | PA Document |
| 00169477211 | OZEMPIC | semaglutide | PEN INJCTR | 2 mg/0.75 mL (8 mg/3 mL) | N | Y | PA Document |
| 00169477212 | OZEMPIC | semaglutide | PEN INJCTR | 2 mg/0.75 mL (8 mg/3 mL) | N | Y | PA Document |
| 00169481530 | RYBELSUS | semaglutide | TABLET | 1.5 mg | N | Y | PA Document |
| 00169431430 | RYBELSUS | semaglutide | TABLET | 14 mg | N | Y | PA Document |
| 00169430330 | RYBELSUS | semaglutide | TABLET | 3 mg | N | Y | PA Document |
| 00169430399 | RYBELSUS | semaglutide | TABLET | 3 mg | N | Y | PA Document |
| 00169480430 | RYBELSUS | semaglutide | TABLET | 4 mg | N | Y | PA Document |
| 00169430730 | RYBELSUS | semaglutide | TABLET | 7 mg | N | Y | PA Document |
| 00169480930 | RYBELSUS | semaglutide | TABLET | 9 mg | N | Y | PA Document |
| 00002147101 | MOUNJARO | tirzepatide | PEN INJCTR | 10 mg/0.5 mL | N | Y | PA Document |
| 00002147180 | MOUNJARO | tirzepatide | PEN INJCTR | 10 mg/0.5 mL | N | Y | PA Document |
| 00002146001 | MOUNJARO | tirzepatide | PEN INJCTR | 12.5 mg/0.5 mL | N | Y | PA Document |
| 00002146080 | MOUNJARO | tirzepatide | PEN INJCTR | 12.5 mg/0.5 mL | N | Y | PA Document |
| 00002145701 | MOUNJARO | tirzepatide | PEN INJCTR | 15 mg/0.5 mL | N | Y | PA Document |
| 00002145780 | MOUNJARO | tirzepatide | PEN INJCTR | 15 mg/0.5 mL | N | Y | PA Document |
| 00002150601 | MOUNJARO | tirzepatide | PEN INJCTR | 2.5 mg/0.5 mL | N | Y | PA Document |
| 00002150680 | MOUNJARO | tirzepatide | PEN INJCTR | 2.5 mg/0.5 mL | N | Y | PA Document |
| 00002149501 | MOUNJARO | tirzepatide | PEN INJCTR | 5 mg/0.5 mL | N | Y | PA Document |
| 00002149580 | MOUNJARO | tirzepatide | PEN INJCTR | 5 mg/0.5 mL | N | Y | PA Document |
| 00002148401 | MOUNJARO | tirzepatide | PEN INJCTR | 7.5 mg/0.5 mL | N | Y | PA Document |
| 00002148480 | MOUNJARO | tirzepatide | PEN INJCTR | 7.5 mg/0.5 mL | N | Y | PA Document |