Exenatide Injection (Byetta®) Prior Authorization Criteria

Byetta Prior Authorization Request Form

Covered Uses

Adjunctive therapy in patients with type 2 diabetes who are taking metformin, a sulfonylurea, a thiazolidinedione, a combination of metformin and a sulfonylurea, or a combination of metformin and a thiazolidinedione, but have not achieved desired HbA1c

Exclusion Criteria

Required Medical Information

Provide A1C level

Age Restrictions

None

Prescriber Restrictions

None

Coverage Duration

1 year

Other Criteria

None