Diabetes, GLP-1 Receptor Agonists and GIP Therapies
PDL Reference Documents
- GLP-1/GIP Receptor Agonist Scan - Apr 04, 2024
- GLP-1 Receptor Agonists and SGLT-2 Inhibitors - Oct 06, 2022
- Newer Diabetes Drugs - Aug 06, 2020
- GLP-1 Receptor Agonists Scan - Mar 21, 2019
- Newer Diabetes Treatments - Jul 26, 2018
- Diabetes Class Update - Sep 28, 2017
- Newer Diabetes Medications and Combinations - Sep 29, 2016
- Diabetes mellitus - Sep 24, 2015
- Diabetes Mellitus - Sep 23, 2014
- Class Update: Newer drugs for Diabetes - Sep 26, 2013
Drug Use Review Documents
Newsletters
- January 2025 - Off-label Uses of GLP-1 Receptor Agonists and Dual GLP-1/GIP Receptor Agonists
- September 2021 - Updates in Heart Failure Therapy: New Drugs and Indications
- September 2020 - Cardiovascular Outcomes Associated with Newer Therapy Classes for Type 2 Diabetes Mellitus
- September 2018 - Management Strategies for Patients with Prediabetes
- March 2016 - Antidiabetic Treatments and Cardiovascular Implications
- October 2013 - Updates and Comparisons of Type 2 Diabetes Treatment Guidelines
- June 2012 - Can The Diabetic War Be Fought By Aggressive Blood Pressure Control?
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 |
| 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) | Y | PA Document | |
| 00480725046 | LIRAGLUTIDE | liraglutide | PEN INJCTR | 3 mg/0.5 mL (18 mg/3 mL) | Y | PA Document | |
| 00169413211 | OZEMPIC | semaglutide | PEN INJCTR | 0.25 mg or 0.5 mg dose (2 mg/1.5 mL) | N | Y | PA Document |
| 00169413212 | OZEMPIC | semaglutide | PEN INJCTR | 0.25 mg or 0.5 mg dose (2 mg/1.5 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 |