Prior Authorization : Preferred Drug List

Hypoglycemics, Glucagon-Like Peptide Agents—Combinations

Note: The Preferred Drug List Quick Reference provides the most current list of preferred and non-preferred drugs in this drug class.

Soliqua and Xultophy

Soliqua and Xultophy are non-preferred drugs in the hypoglycemics, GLP-1 agents—combinations drug class.

PA requests for Soliqua or Xultophy must be completed and signed by the prescriber. PA requests for Soliqua or Xultophy must be submitted using Section VI of the PA/DGA form and the PA/RF. Clinical documentation supporting the use of Soliqua or Xultophy must be submitted with the PA request.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

PA requests for Soliqua or Xultophy may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

For information about general ForwardHealth PA policy for drugs that require PA approval, prescribers and pharmacy providers may refer to the Standard Pharmacy Policy for Covered and Noncovered Drugs topic. Providers may also refer to this topic for information about what may not be considered criteria to support the need for a drug.

Clinical Criteria for Soliqua

Clinical criteria that must be documented for approval of a PA request for Soliqua are all of the following:

• The non-preferred drug is being prescribed in a manner consistent with the FDA-approved product labeling.
• The member has type 2 diabetes mellitus.
• The member's target HbA1c treatment goal has been provided.
• The member's current HbA1c (measured within the past three months) has been provided.
• The member is not taking any meal-time insulin.
• The member has used Lantus concurrently with Adlyxin for at least three consecutive months and reached their target HbA1c treatment goal. Both of the following dose requirements must be met:
  • A Lantus dose must be less than or equal to 60 units taken once daily.
  • An Adlyxin dose must be less than or equal to 20 mcg taken once daily.
• PA requests for Soliqua will only be considered for once daily dosing. PA requests for twice daily dosing will be denied.

A copy of the member's diabetes management medical records must be provided to demonstrate the member meets the clinical criteria listed above.

If the clinical criteria for Soliqua are met, initial PA requests may be approved for up to 183 days.

Renewal PA requests may be approved for up to 365 days if the member has been adherent with the prescribed treatment regimen and had a reduction in their HbA1c compared to their baseline prior to the initiation of Soliqua.

Clinical Criteria for Xultophy

Clinical criteria that must be documented for approval of a PA request for Xultophy are all of the following:

• The non-preferred drug is being prescribed in a manner consistent with the FDA-approved product labeling.
• The member has type 2 diabetes mellitus.
• The member's target HbA1c treatment goal has been provided.
• The member's current HbA1c (measured within the past three months) has been provided.
• The member is not taking any meal-time insulin.
• The member has used Tresiba concurrently with Victoza for at least three consecutive months and reached their target HbA1c treatment goal. Both of the following dose requirements must be met:
  • A Tresiba dose must be less than or equal to 50 units taken once daily.
  • A Victoza dose must be less than or equal to 1.8 mg taken once daily.
• PA requests for Xultophy will only be considered for once daily dosing. PA requests for twice daily dosing will be denied.

A copy of the member's diabetes management medical records must be provided to demonstrate the member meets the clinical criteria listed above.

If the clinical criteria for Xultophy are met, initial PA requests may be approved for up to 183 days.

Renewal PA requests may be approved for up to 365 days if the member has been adherent with the prescribed treatment regimen and had a reduction in their HbA1c compared to their baseline prior to the initiation of Xultophy.