Diabetes, GLP-1 Receptor Agonists

← Back to Class List

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 but eligible patients will encounter a co-pay at the pharmacy.
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
EXENATIDE BYETTA PEN INJCTR Y PA Document Apr 26, 2012
ALBIGLUTIDE TANZEUM PEN INJCTR N PA Document Jan 29, 2015
DULAGLUTIDE TRULICITY PEN INJCTR N PA Document Jan 29, 2015
EXENATIDE MICROSPHERES BYDUREON PEN PEN INJCTR N PA Document  
EXENATIDE MICROSPHERES BYDUREON VIAL N PA Document  
LIRAGLUTIDE VICTOZA 2-PAK PEN INJCTR N PA Document  
LIRAGLUTIDE VICTOZA 3-PAK PEN INJCTR N PA Document  
LIXISENATIDE ADLYXIN PEN INJCTR N PA Document Jan 26, 2017