GLP-1 Agonists – Bydureon, Mounjaro, Rybelsus Prior Authorization Criteria (with Quantity Limit) – Medicare Part D

Prior Authorization with Quantity Limit Criteria for Approval

PA applies to new starts only

Bydureon BCise, Mounjaro, and Rybelsus will be approved when ALL of the following are met:

1. The requested medication will NOT be used for weight loss alone
   AND
2. The patient has a diagnosis of type 2 diabetes mellitus
   AND
3. ONE of the following:
   1. There is evidence of a claim that the patient is currently being treated with the requested medication within the past 180 days
      OR
   2. The prescriber states the patient is currently being treated with the requested medication within the past 180 days
      OR
   3. ALL of the following:
      1. ONE of the following:
         1. The patient’s medication history includes use of a non-glucagon-like peptide-1 (GLP-1) oral diabetes medication (e.g., metformin, an medication containing metformin, glipizide)* within the past 90 days
            OR
         2. The patient had an ineffective treatment response to a non GLP-1 oral diabetes medication (e.g., metformin, a medication containing metformin, glipizide)*
            OR
         3. The patient has an intolerance or hypersensitivity to a non GLP-1 oral diabetes medication (e.g., metformin, a medication containing metformin, glipizide)*
            OR
         4. The patient has an FDA labeled contraindication to a non GLP-1 oral diabetes medication (e.g., metformin, a medication containing metformin, glipizide)*
            AND
      2. The patient does NOT have any FDA labeled contraindications to the requested medication
         AND
      3. The patient will NOT be using the requested medication in combination with another GLP-1 agonist medication, or a medication containing a GLP-1 agonist
         AND
      4. The patient will NOT be using the requested medication in combination with a medication containing a dipeptidyl peptidase-4 (DPP-4) inhibitor
         AND
4. ONE of the following:
   1. The requested quantity (dose) does NOT exceed the program quantity limit
      OR
   2. ALL of the following:
      1. The requested quantity (dose) is greater than the program quantity limit
         AND
      2. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit
         AND
      3. The prescriber has provided information in support of therapy with a higher dose for the requested indication

Length of Approval: 12 months
 

*Oral diabetes medications include: Sulfonylureas, biguanides, meglitinide analogues, alpha-glucosidase inhibitors, DPP-4 inhibitors, bromocriptine, TZDs, SGLT2 inhibitors, DPP4/biguanide combinations, DPP4/TZD combinations, SGLT-2/biguanide combinations, SGLT2/DPP4 combinations, SGLT2/DPP4/biguanide combinations, sulfonylurea/biguanide combinations, sulfonylurea/TZD combinations, TZD/biguanide combinations