Does Blue Cross Blue Shield Cover Trulicity?

What Is Trulicity and Why Does Coverage Status Matter?

Trulicity is a once-weekly injectable GLP-1 receptor agonist containing dulaglutide, approved by the FDA in September 2014 for glycemic control in adults with type 2 diabetes. [1] The drug works by mimicking endogenous glucagon-like peptide-1, stimulating glucose-dependent insulin secretion and suppressing glucagon. [2]

Coverage status matters because the list price of Trulicity runs approximately $900 to $1,000 per 4-pen monthly supply. Without insurance or a manufacturer discount, that cost is prohibitive for most patients. Whether BCBS pays, and how much, can mean the difference between adherence and abandonment.

How GLP-1 Coverage Decisions Are Made

Insurance formulary decisions are made by pharmacy and therapeutics (P&T) committees that weigh clinical evidence, comparative drug costs, and rebate negotiations with manufacturers. The American Diabetes Association's 2024 Standards of Care in Diabetes designate GLP-1 receptor agonists as preferred agents for patients with type 2 diabetes and established atherosclerotic cardiovascular disease (ASCVD), heart failure, or chronic kidney disease. [3]

That guideline language strengthens prior authorization appeals. When a patient's chart documents ASCVD or CKD alongside type 2 diabetes, the ADA recommendation gives the prescribing physician a named guideline to cite.

Dulaglutide's Clinical Evidence Base

The REWIND trial (N=9,901, median follow-up 5.4 years) showed dulaglutide reduced the composite of nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death by 12% versus placebo (HR 0.88, 95% CI 0.79 to 0.99, P=0.026). [4] Insurers use cardiovascular outcome trial data when evaluating formulary placement, so REWIND results support both physician advocacy and patient appeals.

The AWARD-11 trial demonstrated that dulaglutide 4.5 mg reduced HbA1c by a mean of 1.87 percentage points from baseline at 36 weeks, versus 1.54 percentage points with the 1.5 mg dose. [5] Documenting inadequate glycemic control on lower doses can support a step-therapy exception request.

How BCBS Plans Are Structured and Why There Is No Single Answer

Blue Cross Blue Shield is not one company. It is a federation of 34 independent licensees operating across all 50 states, each negotiating its own formularies, tier placements, and prior authorization criteria. [6]

This fragmentation is the core reason there is no single answer to whether "BCBS covers Trulicity." BCBS of Texas, BCBS of Michigan, Anthem (which operates BCBS plans in 14 states), and Highmark all maintain distinct drug lists.

The Four Main Plan Types That Affect Coverage

Employer-sponsored commercial plans. These are the most common and typically offer the most generous Trulicity coverage, often Tier 3 with a copay of $50, $150 per month after the deductible.

Individual and family marketplace plans (ACA). Formularies tend to be narrower. Trulicity may appear on Tier 4 or require step therapy through metformin and a sulfonylurea before approval.

Medicare Advantage (Part D). Coverage depends on the specific Part D plan. The 2023 Inflation Reduction Act capped out-of-pocket drug costs at $2,000 annually for Medicare beneficiaries starting in 2025, which affects total exposure for high-cost biologics like dulaglutide. [7]

Medicaid managed care. State Medicaid programs that contract with BCBS affiliates vary enormously. Some cover dulaglutide; others require failure of two or more preferred agents first.

Reading Your BCBS Formulary

Every BCBS plan publishes an annual formulary document, searchable by drug name. To find Trulicity's current status on your specific plan, log into your BCBS member portal, manage to "Drug List" or "Formulary," and search "dulaglutide" or "Trulicity." The document will list the tier, any quantity limits (typically a maximum of 4 pens per 28 days), and any utilization management requirements such as prior authorization or step therapy.

Prior Authorization for Trulicity Under BCBS Plans

Most BCBS affiliates require prior authorization (PA) for Trulicity. PA is a formal review process in which the insurer evaluates whether the drug is medically necessary for a specific patient before agreeing to pay. [8]

Failing to obtain PA before dispensing means the claim will be rejected at the pharmacy counter.

Typical Prior Authorization Criteria

BCBS PA criteria for Trulicity generally require documentation of all of the following:

• A confirmed type 2 diabetes mellitus diagnosis (ICD-10 E11.x)
• A current HbA1c value, typically above 7.0% or above 8.0% depending on the plan
• Current use of metformin (or a documented intolerance or contraindication to metformin)
• Prescriber attestation that the drug is being used for an FDA-approved indication
• For cardiovascular benefit claims, documentation of ASCVD, heart failure with reduced ejection fraction, or CKD stage 3 or higher

The FDA label for dulaglutide notes that it is approved as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes and to reduce the risk of major adverse cardiovascular events in adults with type 2 diabetes who have established cardiovascular disease or multiple cardiovascular risk factors. [1]

Step Therapy Requirements

Several BCBS plans impose step therapy, requiring a patient to try and fail one or more formulary-preferred drugs before Trulicity is approved. Common required steps include metformin monotherapy (typically 90 days at maximum tolerated dose) and occasionally a sulfonylurea such as glipizide or glimepiride.

If your plan requires step therapy, your physician can document that you completed the required steps. Alternatively, if you have a clinical reason why a required drug is contraindicated (for example, sulfonlyurea avoidance due to hypoglycemia risk in an elderly patient), your physician can request a step-therapy exception citing that clinical rationale.

The FDA Omnibus Appropriations Act of 2016 included provisions encouraging states to adopt step-therapy exception protections, and many states now have laws limiting step-therapy requirements for certain medication classes. [9]

What BCBS Typically Does NOT Cover for Trulicity

Coverage denials cluster around three scenarios.

Off-Label Weight Loss Use

Trulicity is not FDA-approved for weight management. Plans covering Wegovy (semaglutide 2.4 mg) or Zepbound (tirzepatide) for obesity almost never extend that coverage to Trulicity, because dulaglutide lacks an obesity indication. BCBS plans that specifically exclude weight-loss drugs in the plan document will deny claims where the primary diagnosis is obesity (ICD-10 E66.x) rather than type 2 diabetes. [10]

This is a hard wall. Attempting to submit a Trulicity claim under an obesity diagnosis when the patient does not have type 2 diabetes creates a compliance risk for the prescriber and will be denied.

Type 1 Diabetes

Dulaglutide is not approved for type 1 diabetes. Some providers prescribe it off-label as an adjunct to insulin in type 1, but BCBS plans routinely deny coverage for this indication. A few small trials, including a study published in Diabetes Care, suggested modest HbA1c benefit in type 1, but no FDA approval exists for this use. [11]

Exceeding Quantity Limits

Trulicity is dispensed as 1.5 mg, 3.0 mg, or 4.5 mg pens. Most plans limit coverage to four pens per 28-day supply. Prescribing above that quantity requires a separate exception request with documentation of clinical need.

How to Get Trulicity Covered: A Step-by-Step Approach

Patients who are denied coverage or who anticipate a denial can follow a structured approach to maximize approval likelihood.

Step 1: Confirm the Current Formulary Status

Log into the BCBS member portal and download the current formulary PDF. Confirm that Trulicity appears on the formulary at any tier. If it does not appear, ask whether a non-formulary exception process exists.

Step 2: Have Your Physician Submit the PA Request

Your endocrinologist or primary care physician submits the PA electronically through the BCBS provider portal or by fax. The request should include the current HbA1c result (with lab date), the confirmed type 2 diabetes diagnosis, documentation of prior therapy (metformin, other agents), and, if applicable, documentation of ASCVD or CKD to invoke the cardiovascular risk reduction indication. [3]

The ADA's 2024 Standards of Care state: "For patients with type 2 diabetes who have established cardiovascular disease or indicators of high cardiovascular risk, established kidney disease, or heart failure, a GLP-1 receptor agonist or SGLT2 inhibitor with proven cardiovascular benefit is recommended as part of the glucose-lowering regimen." [3] Your physician should quote this guideline verbatim in the PA letter.

Step 3: Request an Expedited Review If Clinically Urgent

BCBS plans are required by the Affordable Care Act to provide a decision within 72 hours for expedited prior authorization requests and within 15 calendar days for standard reviews. If a patient's glucose is severely uncontrolled (HbA1c above 10%), a physician can request expedited review citing clinical urgency. [12]

Step 4: Appeal a Denial

If the PA is denied, request an internal appeal in writing within the plan's appeal window (usually 60 to 180 days from the denial notice). The appeal letter should include updated clinical notes, the ADA guideline citation, the REWIND cardiovascular outcome trial data, and a letter of medical necessity signed by the prescribing physician.

After exhausting internal appeals, patients can request an external independent review, a right guaranteed under the ACA for most employer-sponsored and marketplace plans. [12]

Cost Reduction Strategies When Coverage Is Limited

The Lilly Trulicity Savings Card

Eli Lilly offers a savings card for commercially insured patients. Eligible patients may pay as little as $25 per month for Trulicity when using the card at participating pharmacies. The card cannot be used by Medicare or Medicaid beneficiaries. Enrollment is available through the Lilly Cares Foundation or the Trulicity savings card program on lilly.com.

Patient Assistance Programs

Uninsured patients or those who do not qualify for the savings card may apply for the Lilly Cares Foundation Patient Assistance Program, which provides free medication to qualifying low-income patients. Income thresholds are updated annually.

Switching to a Covered GLP-1 Alternative

If Trulicity remains uncovered or unaffordable, your physician may consider switching to a formulary-preferred GLP-1 receptor agonist. The GLP-1 class includes several agents with comparable glycemic efficacy. The SUSTAIN-6 trial (N=3,297) demonstrated that once-weekly semaglutide 0.5 mg and 1.0 mg reduced the primary MACE composite versus placebo (HR 0.74, 95% CI 0.58 to 0.95, P<0.001 for noninferiority). [13] Many BCBS plans place oral semaglutide (Rybelsus) or injectable semaglutide (Ozempic) on a more favorable tier than dulaglutide, depending on the plan's rebate contracts.

Exenatide extended-release (Bydureon BCise) may also appear on a lower formulary tier on some BCBS plans, though it is less commonly preferred than semaglutide agents in 2024 formularies. The Exenatide Study of Cardiovascular Event Lowering (EXSCEL, N=14,752) showed noninferiority of exenatide ER versus placebo for major cardiovascular events. [14]

Medicare Part D and Trulicity Coverage

Medicare Part D plans, including those administered by BCBS affiliates, have their own formularies. Trulicity has been included on many Part D formularies, typically at Tier 3 or Tier 4.

As of 2025, the Inflation Reduction Act's $2,000 annual out-of-pocket cap for Part D beneficiaries reduces total exposure for patients who require expensive branded agents like dulaglutide. [7] Before the cap, patients in the coverage gap paid 25% of drug costs with no ceiling, which could mean thousands of dollars annually for Trulicity.

Medicare Advantage plans with Part D coverage (MA-PD plans) may have different formulary rules than standalone Part D plans from the same BCBS affiliate. Patients should compare the plan's Evidence of Coverage document, not just the summary of benefits.

The Medicare Part D formulary for any BCBS MA-PD plan is publicly searchable through the Medicare Plan Finder at medicare.gov, which allows drug-level cost lookup by zip code and plan name.

The Extra Help Program

Low-income Medicare beneficiaries may qualify for the Low Income Subsidy (Extra Help) program, administered by the Social Security Administration, which reduces or eliminates Part D premiums, deductibles, and copays. [15] Patients paying full Tier 4 copays for Trulicity under a BCBS Part D plan should check eligibility at ssa.gov/extrahelp.

What Your Physician Should Include in the Medical Necessity Letter

A strong medical necessity letter includes eight specific elements that align with BCBS PA criteria and reduce the likelihood of denial.

1. Patient's full diagnosis with ICD-10 code (E11.x for type 2 diabetes).
2. Most recent HbA1c with date and laboratory name.
3. Current medication list with start dates, doses, and documented response.
4. Documented intolerance or contraindication to any required step-therapy drug.
5. Comorbidities relevant to GLP-1 selection (ASCVD, CKD, heart failure).
6. Citation of the ADA 2024 Standards of Care recommendation for GLP-1 use in high-risk type 2 diabetes. [3]
7. Citation of the REWIND cardiovascular outcome trial for dulaglutide specifically. [4]
8. Statement that the drug is being used for an FDA-approved indication.

Letters that omit the HbA1c value or fail to document prior therapy are the most common reasons PA requests are denied on first submission, based on pharmacy benefit management data compiled across large employer plans. Ensuring all eight elements are present before submission cuts processing delays significantly.

Special Situations

BCBS Federal Employee Program (FEP)

Federal employees covered under the BCBS Federal Employee Program (FEP) have a nationally uniform formulary. In 2024, Trulicity appeared on the FEP formulary under the Basic and Standard Option plans, typically at Tier 3. FEP members can verify current status through the FEP BlueRx pharmacy benefit portal.

BCBS Plans in States With Step-Therapy Reform Laws

As of 2024, more than 25 states have enacted step-therapy exception laws that require insurers to grant exceptions within defined timeframes when a prescriber documents clinical rationale. [9] Patients in these states have a legal right to request an exception if a step-therapy requirement conflicts with the prescriber's clinical judgment. Your physician's office should be familiar with your state's specific law.

Employer Self-Funded Plans

Large employers often self-fund their health benefits and contract with a BCBS affiliate only for administrative services (an "ASO" arrangement). Self-funded plans are governed by ERISA rather than state insurance law, which means state step-therapy reform laws may not apply. However, self-funded plan sponsors can modify formularies at any plan year, so a drug that is excluded in 2024 might be covered in 2025 if the employer's benefits committee adds it.

Key Numbers to Know Before Calling BCBS

• Trulicity list price: Approximately $975 per month (4 pens, 1.5 mg dose) as of 2024.
• Typical Tier 3 copay: $50, $150 per 30-day supply after deductible, on most commercial BCBS plans.
• PA turnaround time: Up to 15 calendar days standard, 72 hours expedited. [12]
• Appeal window: Typically 60 to 180 days from denial date (varies by plan).
• Lilly savings card maximum benefit: Up to $150 per month off out-of-pocket costs for eligible commercially insured patients.
• REWIND NNT for MACE prevention: Approximately 80 patients treated for 5 years to prevent one MACE event. [4]