April 2019
Therapeutic area - Hypoglycemics
Preferred
Byetta
Bydureon Pen
Victoza
Nonpreferred
Adlyxin
Bydureon BCise
Ozempic
Trulicity
Combination GLP1-insulin products (Soliqua and Xultophy) are under separate PA criteria sheet. See PA criteria sheet, “Basal insulin and GLP-1-receptor agonist combination”
Preferred | Quantity Limits |
Byetta (5 mcg and 10 mcg per dose) | 2.4mL |
Bydureon Pen | 4 pens |
Victoza 2-Pak | 6mL |
Victoza 3-Pak | 9mL |
Nonpreferred | Quantity Limits |
Adlyxin (10 mcg and 20 mcg per dose) | 6mL |
Bydureon BCise | 3.4mL |
Ozempic 1-Pen | 1.5mL |
Ozempic 2-Pen | 3mL |
Trulicity | 2mL |
MHCP Provider Call Center 651-431-2700 or 800-366-5411