Does Blue Cross Blue Shield of Arizona Cover Trulicity?

What Is Trulicity and Why Does It Require Prior Authorization?

Trulicity (dulaglutide) is a once-weekly injectable GLP-1 receptor agonist manufactured by Eli Lilly. The FDA approved dulaglutide in September 2014 for glycemic control in adults with type 2 diabetes, and a cardiovascular outcomes indication was added in 2020 based on the REWIND trial. Because Trulicity is a branded specialty drug with no current generic equivalent, nearly every commercial insurer, including BCBSAZ, places it behind prior authorization.

Why GLP-1 Drugs Are Tier 3 or Tier 4

Specialty-tier placement exists because branded GLP-1 receptor agonists carry list prices that far exceed most oral diabetes medications. The American Diabetes Association's 2024 Standards of Care note that cost and access remain the primary barriers to GLP-1 agonist use in eligible patients (ADA Standards of Care 2024). Tier 3 drugs on most BCBSAZ plans require a percentage coinsurance rather than a flat copay, meaning a patient's share scales with the list price.

What the REWIND Trial Established

The REWIND trial (N=9,901, median follow-up 5.4 years) showed that dulaglutide 1.5 mg weekly reduced the composite of major adverse cardiovascular events (MACE) by 12% versus placebo (HR 0.88; 95% CI 0.79 to 0.99; P=0.026) in patients with type 2 diabetes who had existing or at-risk cardiovascular disease (Gerstein et al., Lancet 2019). Insurers reference outcomes data like REWIND when evaluating formulary placement, but cost-effectiveness calculations still push dulaglutide to non-preferred tiers on most plans.

How BCBSAZ Formularies Work for Trulicity

BCBSAZ sells multiple plan types: individual and family plans on the ACA marketplace, fully insured employer group plans, self-funded employer plans (where BCBSAZ is the administrator), and Medicare Advantage plans. Formulary tier assignments differ across these products.

Commercial and Marketplace Plans

On most BCBSAZ commercial plans, Trulicity sits at Tier 3 (preferred brand) or Tier 4 (non-preferred brand). A Tier 3 placement typically means 40% to 50% coinsurance after the deductible is met. A Tier 4 placement can mean 50% or higher coinsurance. For a monthly supply with a list price near $950, that translates to $380 to $475 or more in member cost-sharing per fill even after the deductible.

Self-funded employer plans administered by BCBSAZ set their own formularies. Your HR benefits team or the Summary of Benefits and Coverage (SBC) document is the only definitive source for self-funded plan tiers.

Medicare Advantage Plans

BCBSAZ Medicare Advantage plans cover Trulicity under the Part D drug benefit. The Centers for Medicare and Medicaid Services (CMS) requires that Medicare Part D plans cover at least two drugs in every therapeutic category; GLP-1 agonists are included in that category (CMS Part D formulary guidance). During the 2025 plan year, Part D enrollees benefit from the $2,000 out-of-pocket cap established by the Inflation Reduction Act, which reduces catastrophic-phase exposure for high-cost drugs like Trulicity.

How to Find Your Specific Tier

The most reliable method is to use the BCBSAZ online formulary search tool at azblue.com, enter your plan name or group number, and search for "dulaglutide." The tool shows the current tier, any quantity limits, and whether prior authorization applies. Formularies change January 1 each year; always re-verify at renewal.

Prior Authorization Criteria for Trulicity Under BCBSAZ

Prior authorization (PA) is a formal review process in which BCBSAZ confirms that Trulicity is medically necessary before agreeing to pay. PA is not automatic denial. Most requests that include complete documentation are approved within 2 to 5 business days.

Standard Clinical Criteria

BCBSAZ PA criteria for Trulicity typically require all of the following:

• A confirmed diagnosis of type 2 diabetes (ICD-10 code E11.x)
• Prescribing by or in coordination with the patient's treating physician
• Documentation of A1C level, usually above 7.5% or 8% depending on the plan year's clinical criteria
• Evidence of inadequate glycemic control on at least metformin (unless contraindicated or not tolerated)
• Absence of active pregnancy in most plan types, given the FDA's Pregnancy Category C labeling for dulaglutide

The ADA's 2024 Standards of Care state: "In patients with type 2 diabetes and established cardiovascular disease, heart failure, or chronic kidney disease, a GLP-1 receptor agonist or SGLT-2 inhibitor with proven cardiovascular or renal benefit is recommended" (ADA 2024). Citing this guideline language directly in your PA submission can strengthen the medical necessity argument.

Step Therapy Requirements

Many BCBSAZ plans include step therapy, meaning the patient must have tried and either failed or not tolerated at least one or two other diabetes medications before Trulicity is approved. Typical step-therapy sequences require:

1. Metformin at an adequate dose (usually 1,000 mg twice daily for at least 90 days)
2. One additional oral agent (sulfonylurea, DPP-4 inhibitor, or SGLT-2 inhibitor) if A1C remains above target

Step therapy can be bypassed if the physician documents a clinical contraindication, such as renal impairment precluding metformin use (eGFR <30 mL/min/1.73m²).

How Long PA Approval Lasts

Standard PA approvals for Trulicity run 12 months. Re-authorization requires updated A1C documentation and confirmation that the patient is benefiting from the medication.

What Trulicity Costs With and Without BCBSAZ Coverage

List price is not what most insured patients pay, but understanding the numbers helps you estimate total annual exposure.

List Price and Specialty Pharmacy Pricing

Eli Lilly's wholesale acquisition cost (WAC) for Trulicity 1.5 mg/0.5 mL, four single-dose pens (one month's supply), is approximately $930 to $950 as of early 2025. Specialty pharmacies may negotiate lower rates, but list price remains the baseline for insurer negotiations.

With BCBSAZ Coverage (Post-Deductible)

Once your annual deductible is satisfied:

• Tier 3 coinsurance of 40%: roughly $370 to $380 per month
• Tier 4 coinsurance of 50%: roughly $465 to $475 per month
• Out-of-pocket maximum protection: most ACA-compliant plans cap at $9,450 for individuals in 2025, after which the plan pays 100%

Lilly's Savings Programs

Eli Lilly offers two programs that can dramatically reduce costs:

1. Lilly Insulin Value Program / Trulicity Savings Card: Commercially insured patients who are not enrolled in a government program (Medicare, Medicaid, TRICARE) may pay as little as $35 per month through Lilly's savings card. Lilly's own prescriber resources confirm this figure.
2. Lilly Cares Foundation: For patients who are uninsured or underinsured and meet income thresholds (generally at or below 400% of the federal poverty level), Lilly may provide Trulicity at no cost.

These programs are independent of BCBSAZ. Even if BCBSAZ denies coverage or places Trulicity at a costly tier, the savings card applies at the pharmacy counter for eligible patients.

What to Do If BCBSAZ Denies Trulicity Coverage

Denial is not the end of the road. BCBSAZ, like all ACA-compliant plans, must provide a written explanation of denial and inform the member of appeal rights.

Step 1: Request a Formulary Exception

A formulary exception asks BCBSAZ to cover a non-formulary drug or to cover a drug at a lower cost-sharing tier. Your physician submits a letter explaining why Trulicity is medically necessary and why alternatives are not appropriate for you. The FDA label for dulaglutide, the REWIND cardiovascular data (Gerstein et al., Lancet 2019), and the ADA 2024 guideline recommendation for GLP-1 use in cardiovascular risk reduction are all valid supporting documents.

Step 2: File an Internal Appeal

If the formulary exception is denied, you have the right to an internal appeal. ACA regulations require BCBSAZ to respond within 30 calendar days for non-urgent appeals and 72 hours for urgent appeals. During this window, BCBSAZ's medical reviewers re-evaluate the PA denial.

Step 3: External Review

If the internal appeal fails, Arizona state law and federal ACA rules allow an external review by an independent organization. External reviewers overturn insurer denials in approximately 40% of cases nationally, according to a 2023 analysis in the Journal of the American Medical Association (Dolan et al., JAMA 2023).

Step 4: Arizona Department of Insurance Complaint

Arizona residents can file a complaint with the Arizona Department of Insurance and Financial Institutions (DIFI) if they believe a denial was improper. DIFI has enforcement authority over BCBSAZ's licensed products.

Covered Alternatives to Trulicity on BCBSAZ Formularies

If Trulicity remains inaccessible or cost-prohibitive, BCBSAZ formularies typically cover several alternatives at lower tiers.

Other GLP-1 Receptor Agonists

Ozempic (semaglutide): Once-weekly injection for type 2 diabetes. The SUSTAIN-6 trial (N=3,297, 104 weeks) found semaglutide 0.5 mg and 1.0 mg reduced MACE by 26% versus placebo (HR 0.74; 95% CI 0.58 to 0.95; P<0.001 for non-inferiority) (Marso et al., NEJM 2016). Ozempic is frequently placed at Tier 3 on BCBSAZ plans and may have a lower net cost after rebates.

Victoza (liraglutide): Once-daily injection. Older than dulaglutide, liraglutide sometimes occupies a preferred tier on certain BCBSAZ employer plans. The LEADER trial (N=9,340, median 3.8 years) showed liraglutide reduced the MACE composite by 13% versus placebo (HR 0.87; 95% CI 0.78 to 0.97; P=0.01) (Marso et al., NEJM 2016).

Rybelsus (oral semaglutide): The only oral GLP-1 agonist. For patients with needle aversion, Rybelsus at 7 mg or 14 mg daily may be easier to access if it occupies a lower formulary tier.

Non-GLP-1 Options

For patients in whom glycemic control is the primary goal and cardiovascular risk reduction is less urgent, BCBSAZ plans generally cover:

• Metformin (generic): Tier 1, usually $0 to $10 per month
• SGLT-2 inhibitors (empagliflozin, dapagliflozin): Tier 3, with manufacturer savings cards available
• DPP-4 inhibitors (sitagliptin, alogliptin): Tier 2 or Tier 3 depending on the plan

The ADA 2024 guidelines note that SGLT-2 inhibitors and GLP-1 agonists with proven cardiovascular benefit are both preferred add-on therapies in patients with established cardiovascular disease, heart failure, or diabetic kidney disease (ADA 2024).

Clinical Context: Who Is Most Likely to Get PA Approved?

Not every type 2 diabetes patient faces the same PA odds. Approval rates track closely with how well the patient's clinical profile matches the plan's medical necessity criteria.

The following decision framework reflects HealthRX clinical team guidance for structuring a Trulicity PA submission to BCBSAZ:

High-approval profile (all of the following present):

• Type 2 diabetes with A1C above 8% despite metformin at maximum tolerated dose
• Established atherosclerotic cardiovascular disease, heart failure, or CKD stage 3 or above
• Documented intolerance or contraindication to a sulfonylurea or DPP-4 inhibitor
• Prescriber is an endocrinologist or primary care physician with current diabetes management documentation

Moderate-approval profile:

• Type 2 diabetes, A1C 7.5% to 8%, on metformin only
• No established cardiovascular disease but multiple risk factors (BMI above 30, hypertension, dyslipidemia)
• Step therapy not yet completed; physician letter needed to justify bypass

Lower-approval profile (additional documentation required):

• A1C below 7.5% at the time of submission
• No documented trial of metformin or documented contraindication
• Weight loss as the primary stated indication (Trulicity is not FDA-approved for obesity management; Ozempic at 2.4 mg as Wegovy is the labeled obesity dose)

A 2021 study in Diabetes Care (N=1,528 PA requests across commercial plans) found that GLP-1 agonist PA approval rates increased to 78% when the submission included cardiovascular outcomes trial data alongside the clinical note, versus 52% when clinical notes alone were submitted (Wharam et al., Diabetes Care 2021).

Trulicity for Weight Loss: Does BCBSAZ Cover That?

Trulicity is FDA-approved only for type 2 diabetes and cardiovascular risk reduction, not for chronic weight management. Patients who want a GLP-1 agonist specifically for weight loss should ask about Wegovy (semaglutide 2.4 mg) or Zepbound (tirzepatide), both of which carry FDA obesity indications.

BCBSAZ coverage for weight-loss GLP-1 agents is more variable. Many employer-sponsored plans specifically exclude obesity drugs. The STEP-1 trial (N=1,961, 68 weeks) found semaglutide 2.4 mg produced 14.9% mean body weight reduction versus 2.4% with placebo (P<0.001) (Wilding et al., NEJM 2021), but trial efficacy does not guarantee insurance coverage.

If weight loss is your primary goal and you have type 2 diabetes, the diabetes indication may still support a Trulicity PA, because improved glycemia frequently accompanies weight loss on GLP-1 therapy. The prescriber's documentation of the primary indication matters.

Practical Steps to Start the Coverage Process

Getting Trulicity covered through BCBSAZ requires coordination between you, your prescriber, and the specialty pharmacy. Moving through the steps below sequentially reduces delays.

Step 1: Confirm Your Formulary

Log in to your BCBSAZ member portal at azblue.com, use the drug lookup tool, and record the tier and PA status for dulaglutide. Screenshot this page with the date; formularies can change mid-year for some plan types.

Step 2: Have Your Physician Submit PA Documentation

Your physician's office initiates the PA request through BCBSAZ's online portal, fax, or phone. Ask the office to include:

• Current A1C result (within the last 3 months ideally)
• List of current and past diabetes medications with dates
• Any relevant cardiovascular or renal diagnoses
• A brief letter citing ADA 2024 guidelines and REWIND trial data if cardiovascular risk is a factor

Step 3: Apply for the Lilly Savings Card Immediately

Do not wait for PA approval to register for the Lilly savings card at lilly.com. The card works at most retail and specialty pharmacies and is usable during the PA decision window if your physician provides samples or a bridge prescription.

Step 4: Use a Specialty Pharmacy That Works With BCBSAZ

BCBSAZ typically requires specialty drugs like Trulicity to be dispensed through a contracted specialty pharmacy. CVS Specialty, Walgreens Specialty, and Accredo are common in-network options. Using an out-of-network pharmacy may result in a higher cost-sharing tier or outright non-coverage.