CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Trulicity (dulaglutide) prior authorization

Prior authorization form and requirements for Trulicity (dulaglutide) for members covered through OptumRx/Blue Cross Blue Shield - South Carolina; intended for prescribers submitting PA requests.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyTrulicity (dulaglutide) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests via CoverMyMeds (gocovermymeds.com/OptumRx) or fax the completed form to 844-403-1029.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

gocovermymedsonline PA partner

844-403-1029fax

Type 2 DMrequired diagnosis

metforminfirst-line to try

>4 pens/28dquantity threshold

Coverage Criteria

Initial Authorization

Covered when ALL of the following are met:

Initial Authorization: Patient has a diagnosis of Type 2 diabetes mellitus

Question 1 on form must be 'Yes'

Prior Therapy: Patient has experienced an inadequate treatment response, intolerance, or contraindication to metformin with documentation of medications tried, dates of trials, and reason

Question 2 on form; provider must document medications tried, dates, and reason

Quantity Need: If patient requires more than four pens or syringes per 28 days (or 12 per 84 days), this must be indicated and documented>4 pens/28 days (or 12/84 days)

Question 3 on form

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyTrulicity (dulaglutide) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests via CoverMyMeds (gocovermymeds.com/OptumRx) or fax the completed form to 844-403-1029.

SourceLink

On This Page

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No explicit clinical exclusions are listed on the prior authorization form. The form focuses on confirming the diagnosis of Type 2 diabetes mellitus, documenting prior therapy with metformin, and capturing quantity needs rather than listing specific excluded clinical conditions.

The form states that requests may be denied unless all required information is received. Providers must complete the clinical questions and supply the requested documentation to avoid denial of the authorization.

Initial Therapy

Initial therapy

Initial authorization requires confirmation of diagnosis and prior metformin trial documentation.

Diagnosis of Type 2 diabetes mellitus is confirmed on the form

Question 1 must be answered 'Yes'

Metformin trial: Documentation that the patient experienced inadequate response, intolerance, or has a contraindication to metformin; include medications tried, dates of trials, and reason for failure/intolerance/contraindication

Question 2 on form; required details must be provided on PA form

Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required. Submit prior authorization requests using CoverMyMeds (gocovermymeds.com/OptumRx) for faster processing and possible real-time determinations, or fax the completed prior authorization form to 844-403-1029.

Online: CoverMyMeds (gocovermymeds.com/OptumRx)
Fax: 844-403-1029
Questions: OptumRx prior authorization support 855-811-2218 (Mon–Fri 8 a.m. to ?)

Documentation Required

Required Documentation on PA Form

Documentation required on the prior authorization form includes complete provider and member identification, medication details, and clinical information. Ensure fields such as member name, insurance ID, provider name, NPI, specialty, dates of birth, office contact/fax, medication name, strength, directions for use, diagnosis, and prescriber signature are completed. Also provide clinical rationale, prior medication trials, dates, and reasons for discontinuation or intolerance.

Member and provider identifiers: member name, insurance ID#, provider name, NPI#, specialty, DOB, office phone/fax, address, city, state, ZIP
Medication details: medication name, strength, directions for use
Clinical information: diagnosis (e.g., Type 2 diabetes mellitus), prior medication trials with dates and reasons for failure/intolerance/contraindication
Prescriber signature and date

Step Therapy

Metformin Trial Requirement

Metformin trial requirement: approval requires documentation that the patient had an inadequate response to, intolerance of, or a contraindication to metformin. Include the specific metformin regimen tried, dates of the trial, and the reason for discontinuation or failure.

Document inadequate response, intolerance, or contraindication to metformin
Provide medication name(s), dates of trial, and reason for failure/intolerance/contraindication

Denial Risk

Incomplete Information May Lead to Denial

Incomplete information may lead to denial. This request may be denied unless all required information is received; ensure the PA form is fully completed and any supporting documentation is attached.

Incomplete or missing member/provider IDs, medication details, clinical rationale, or prescriber signature can result in denial
Attach supporting clinical records when applicable

Coding & Quantity Thresholds

Pen/syringe quantity threshold

ThresholdMore than four pens or syringes per 28 days (or 12 pens/syringes per 84 days)

Related question on formQuestion 3 asks whether the patient requires more than four pens or syringes per 28 days (or 12 per 84 days)

Documentation implicationIf 'Yes', quantity need must be indicated and documented on the PA form

Quantity Limits

Trulicity (dulaglutide) quantity documentation

DrugTrulicity (dulaglutide)

Quantity threshold requiring documentationMore than 4 pens or syringes per 28 days (or 12 per 84 days)

Form actionQuestion 3 requires the prescriber to indicate if the patient requires >4 pens/28 days and document accordingly

Definitions

Metformin trial documentation

RequirementDocument inadequate treatment response, intolerance, or contraindication to metformin

Details to includeMedications tried, date(s) of trial(s), and reason for failure/intolerance/contraindication

Form locationQuestion 2 on the clinical information section requests this documentation

Type 2 diabetes mellitus diagnosis

Required diagnosisType 2 diabetes mellitus must be present for the request

Form verificationQuestion 1 asks whether the patient has a diagnosis of Type 2 diabetes mellitus (Yes/No)

Clinical implicationAuthorization is contingent on confirmation of this diagnosis as indicated on the PA form

Step Therapy Requirements

Step	Requirement
1	Documentation that the patient has experienced an inadequate treatment response, intolerance, or contraindication to metformin; provider must document medication(s) tried, dates of trial(s), and reason(s)

Background

Trulicity (dulaglutide) is a GLP-1 receptor agonist indicated for management of Type 2 diabetes mellitus. The prior authorization form is designed to confirm the patient has a diagnosis of Type 2 diabetes mellitus, document an inadequate response, intolerance, or contraindication to metformin (including medications tried, dates, and reasons), and record dosing/quantity needs such as whether the patient requires more than four pens or syringes per 28 days (or 12 per 84 days).