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)

Authorization form

Optimized (07/2020)

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.

Go to Medicaid ADL