Is Victoza Covered by Insurance? Criteria, Copay, Appeal
Most insurance plans cover Victoza for type 2 diabetes, usually with prior authorization. It is approved for type 2 diabetes and heart risk, not weight loss.
- Plans tracked
- 18
- Approved for
- Type 2 diabetes and heart risk
Victoza overview
Its half-life is about 13 hours. After 13 h, half remains, and about 3% remains after five half-lives (2.7 d).
In the LEAD-3 trial for type 2 diabetes, people lost 2.5 kg over 52 weeks, compared with 1.1 kg on placebo.
Sources: FDA label (DailyMed).
Does insurance cover Victoza?
| Plan | For type 2 diabetes | For weight loss | Prior authorization |
|---|---|---|---|
| Medicare | Covered by Part D plans | Bridge program only | Required |
| Medicaid | Covered | Varies by state | Required |
 Aetna | Covered on formulary | Employer option | Required |
 Cigna (Evernorth / Express Scripts) | Covered on formulary | Plan dependent | Required |
 UnitedHealthcare (Optum Rx) | Covered on formulary | Plan dependent | Required |
 Blue Cross Blue Shield | Covered on formulary | Plan dependent | Required |
 Kaiser Permanente | Covered on formulary | Plan dependent | Required |
 CVS Caremark | Covered on formulary | Plan sponsor choice | Required |
| Express Scripts | Covered on formulary | Plan sponsor choice | Required |
| Optum Rx | Covered on formulary | Plan sponsor choice | Required |
 Humana | Covered by Part D plans | Bridge program only | Required |
| TRICARE | Covered with PA | Prime and Select only | Required |
| VA (Veterans Health Administration) | Covered | Covered with criteria | Required |
 GEHA | Covered | Covered with PA | Required |
 Ambetter (Centene) | Covered on formulary | Excluded | Required |
| ACA Marketplace plans | Common | Rare | Required |
 Navitus | Covered on formulary | Plan sponsor choice | Not listed |
 Amerigroup (Elevance Medicaid) | Covered with PA | Follows state Medicaid | Required |
Plan policies (18)
medicare.gov, KFF 1 2, aetna.com, static.cigna.com, uhcprovider.com, bluecrossma.org, healthy.kaiserpermanente.org, cvshealth.com, express-scripts.com, welcome.optumrx.com, humana.com, militaryrx.express-scripts.com, va.gov, geha.com, ambetterhealth.com, navitus.com, provider.amerigroup.com.
Prior authorization checklist
- Type 2 diabetes or heart risk appears on your chart as an approved use of Victoza.
- Recent A1C results.
- Diabetes drugs you have tried so far.
Sources: humana.com, medicare.gov, CMS, aetna.com.
The appeal, if you are denied
| Denial reason | What to send or ask |
|---|---|
| Prior authorization missing | Your prescriber sends the plan's form with your type 2 diabetes diagnosis and recent A1C included. |
| The plan wants another drug first | Ask the plan for a list of the drugs it wants you to try first, and send records of drugs you have tried so far. |
| The drug is not on the plan's list | Ask the plan which GLP-1 it prefers instead, and request a formulary exception. |
- Get a copy of the denial letter. It names the specific rule that you did not meet.
- Your prescriber files chart notes that address the rule along with the appeal.
- If the plan's appeal is unsuccessful, request an external review by an independent reviewer.
State and plan variation
The same insurer can approve coverage in one state or employer plan but decline it in another.
- Type 2 diabetes and TRICARE coverage: PA required
State by state, the Medicaid rules are set. Medicaid rules are set by each state. Right now, coverage for GLP-1s for weight loss applies in 10 states: Delaware, Kansas, Michigan, Minnesota and Mississippi. Coverage also applies in Missouri, North Carolina, Tennessee, Virginia and Wisconsin. A comparison of all states.
Source: militaryrx.express-scripts.com.