Glucagon-like peptide-1 agonists (GLP-1s)
Use this form for:
- Adlyxin® (lixisenatide)
- Bydureon® (exenatide extended-release)
- Byetta® (exenatide)
- Ozempic® (semaglutide)
- Trulicity® (dulaglutide)
- Victoza® (liraglutide)
Priority Health Medicaid no longer utilizes drug-specific prior authorization forms for drugs covered under the pharmacy benefit.
Visit the Approved Drug List (ADL) to search by drug name and view the criteria and PA form.