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Sodium-glucose Co-transporter (SGLT-2) Inhibitors and Combinations Step Therapy and Quantity Limit Program Summary
Policy Number: PH-91135
This program applies to Blue Partner, Commercial, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace formularies.
POLICY REVIEW CYCLE
Effective Date |
Date of Origin |
04-01-2024 |
|
FDA APPROVED INDICATIONS AND DOSAGE
Agent(s) |
FDA Indication(s) |
Notes |
Ref# |
Brenzavvy®, Bexagliflozin Tablet |
As an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus Limitation of Use: Not recommended for use to improve glycemic control in patients with type 1 diabetes mellitus |
|
19 |
Farxiga® (dapagliflozin) Tablet |
As an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus To reduce the risk of hospitalization for heart failure in adults with type 2 diabetes mellitus and established cardiovascular disease or multiple cardiovascular risk factor To reduce the risk of hospitalization for heart failure in adults with type 2 diabetes mellitus and either established cardiovascular disease or multiple cardiovascular risk factors. To reduce the risk of sustained eGFR decline, end stage kidney disease, cardiovascular death, and hospitalization for heart failure in adults with chronic kidney disease at risk of progression Limitations of Use:
|
|
2 |
Glyxambi® (empagliflozin/linagliptin) Tablet |
To improve glycemic control in adults with type 2 diabetes mellitus. To reduce the risk of cardiovascular death in adults with type 2 diabetes mellitus and established cardiovascular disease. Limitations of Use:
|
DPP-4 Inhibitor Combinations |
14 |
Inpefa™ (sotagliflozin) |
To reduce the risk of cardiovascular death, hospitalization for heart failure, and urgent heart failure visit in adults with:
|
|
18 |
Invokamet® (canagliflozin/metformin) Tablet |
As an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus Canagliflozin is indicated to reduce the risk of major adverse cardiovascular events in adults with type 2 diabetes mellitus and established cardiovascular disease Canagliflozin is indicated to reduce the risk of end-stage kidney disease, doubling of serum creatinine, cardiovascular death, and hospitalization for heart failure in adults with type 2 diabetes mellitus and diabetic nephropathy with albuminuria Limitations of Use: Not recommended for use to improve glycemic control in patients with type 1 diabetes mellitus |
|
3 |
Invokamet® XR (canagliflozin/metformin ER) Tablet |
As an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus when treatment with both canagliflozin and metformin HCl is appropriate Canagliflozin is indicated to reduce the risk of major adverse cardiovascular events in adults with type 2 diabetes and established cardiovascular disease Canagliflozin is indicated to reduce the risk of end-stage kidney disease, doubling of serum creatinine, cardiovascular death, and hospitalization for heart failure in adults with type 2 diabetes mellitus and diabetic nephropathy with albuminuria Limitation of Use: Not recommended in patients with type 1 diabetes mellitus or diabetic ketoacidosis |
|
3 |
Invokana® (canagliflozin) Tablet |
As an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus To reduce the risk of major cardiovascular events in adults with type 2 diabetes mellitus and established cardiovascular disease To reduce the risk of end-stage kidney disease, doubling of serum creatinine, cardiovascular death, and hospitalization for heart failure in adults with type 2 diabetes mellitus and diabetic nephropathy with albuminuria Limitations of Use:
|
|
1 |
Jardiance® (empagliflozin) |
To reduce the risk of cardiovascular death and hospitalization for heart failure in adults with heart failure. To reduce the risk of sustained decline in eGFR, end-stage kidney disease, cardiovascular death, and hospitalization in adults with chronic kidney disease at risk of progression. To reduce the risk of cardiovascular death in adults with type 2 diabetes mellitus and established cardiovascular disease. As an adjunct to diet and exercise to improve glycemic control in adults and pediatric patients aged 10 years and older with type 2 diabetes mellitus. Limitations of Use:
|
|
4 |
Qtern® (dapagliflozin/saxagliptin) Tablet |
As an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus Limitation of Use: Not recommended for patients with type 1 diabetes mellitus. |
DPP-4 Inhibitor Combinations |
15 |
Segluromet® (ertugliflozin/metformin) Tablet |
As an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus Limitation of Use: Not for the treatment of type 1 diabetes mellitus or diabetic ketoacidosis |
|
9 |
Steglatro® (ertuglifozin) Tablet |
As an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus Limitation of Use: Not recommended in patients with type 1 diabetes mellitus
|
|
8 |
Steglujan® (ertugliflozin/sitagliptin) Tablet |
As an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus Limitations of Use: Not recommended for use to improve glycemic control in patients with type 1 diabetes mellitus Has not been studied in patients with a history of pancreatitis |
DPP-4 Inhibitor Combinations |
16 |
Synjardy® (empagliflozin/metformin) Tablet |
As an adjunct to diet and exercise to improve glycemic control in adults and pediatric patients aged 10 years and older with type 2 diabetes mellitus Empagliflozin, when used as a component of Synjardy or Synjardy XR, is indicated in adults with type 2 diabetes mellitus to reduce the risk of:
Limitations of Use:
|
|
6 |
Synjardy® XR (empagliflozin/metformin ER) Tablet |
As an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus Empagliflozin, when used as a component of Synjardy or Synjardy XR, is indicated in adults with type 2 diabetes mellitus to reduce the risk of:
Limitations of Use:
|
|
7 |
Trijardy XR® (empagliflozin/linagliptin/metformin ER) Tablet |
As an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus Empagliflozin is indicated to reduce the risk of cardiovascular death in adults with type 2 diabetes mellitus and established cardiovascular disease Limitations of Use:
|
DPP-4 Inhibitor Combinations
|
17 |
Xigduo® XR (dapagliflozin/metformin ER) Tablet |
As an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus Dapafliflozin is indicated to reduce:
Limitations of Use:
|
|
5 |
See package insert for FDA prescribing information: https://dailymed.nlm.nih.gov/dailymed/index.cfm
CLINICAL RATIONALE
Diabetes |
The American Diabetes Association (ADA) recommends the following guidelines:(10,11)
Healthy lifestyle behaviors, diabetes self-management, education, and support, avoidance of clinical inertia, and social determinants of health should be considered in the glucose-lowering management of type 2 diabetes. Pharmacologic therapy should be guided by person-centered treatment factors, including comorbidities and treatment goals. Pharmacotherapy should be started at the time type 2 diabetes is diagnosed unless there are contraindications. Pharmacologic approaches that provide the efficacy to achieve treatment goals should be considered, such as metformin or other agents, including combination therapy, that provide adequate efficacy to achieve and maintain treatment goals. In adults with type 2 diabetes and established/high risk of atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), and/or chronic kidney disease (CKD), the treatment regimen should include agents that reduce cardiorenal risk.(11) Pharmacologic approaches that provide the efficacy to achieve treatment goals should be considered, specified as metformin or agent(s), including combination therapy, that provide adequate efficacy to achieve and maintain treatment goals. In general, higher-efficacy approaches have greater likelihood of achieving glycemic goals, with the following considered to have very high efficacy for glucose lowering: the GLP-1 RAs dulaglutide (high dose) and semaglutide, the gastric inhibitory peptide (GIP) and GLP-1 RA tirzepatide, insulin, combination oral therapy, and combination injectable therapy. Weight management is an impactful component of glucose-lowering management in type 2 diabetes. The glucose-lowering treatment regimen should consider approaches that support weight management goals, with very high efficacy for weight loss seen with semaglutide and tirzepatide.(11) Metformin is effective and safe, is inexpensive, and may reduce risk of cardiovascular events and death. Metformin is available in an immediate-release form for twice-daily dosing or as an extended-release form that can be given once daily. Compared with sulfonylureas, metformin as first-line therapy has beneficial effects on A1C, weight, and cardiovascular mortality. For people with type 2 diabetes and established ASCVD or indicators of high ASCVD risk, HF, or CKD, an SGLT2 inhibitor and/or GLP-1 RA with demonstrated CVD benefit is recommended as part of the glucose-lowering regimen independent of A1C, independent of metformin use and in consideration of person-specific factors. For people without established ASCVD, indicators of high ASCVD risk, HF, or CKD, medication choice is guided by efficacy in support of individualized glycemic and weight management goals, avoidance of side effects (particularly hypoglycemia and weight gain), cost/access, and individual preferences.(11) Dapagliflozin and empagliflozin have been shown to significantly reduce the risk of worsening heart failure or cardiovascular death independently of diabetes status.(2,4) Angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), angiotensin receptor-neprilysin inhibitors (ARNIs), funny current channel inhibitors (e.g., Corlanor), aldosterone antagonists, beta blockers, isosorbide dinitrate and hydralazine are all medications commonly used for heart failure with reduced ejection fraction (HFrEF).(12,13) |
Safety |
Invokamet, Invokamet XR, Segluromet, Synjardy, Synjardy XR, Trijardy XR, and Xigduo XR all have a black box warning for lactic acidosis due to their metformin component:(3,5-7,9,17)
Brenzavvy, Farxiga, Invokana, Jardiance, Steglatro, and Glyxambi are contraindicated in patients on dialysis.(1,2,4,8,14,19) Inpefa is contraindicated in history of serious hypersensitivity reaction to Inpefa.(18) Invokamet and Invokamet XR are contraindicated in patients with severe renal impairment, acute or chronic metabolic acidosis, including diabetic ketoacidosis.(3) Segluromet, Synjardy, Synjardy XR, Xigduo XR, and Trijardy XR are contraindicated in patients with severe renal impairment, end stage renal disease (ESRD), patients on dialysis, and patients with acute or chronic metabolic acidosis, including diabetic ketoacidosis.(5-7,9,17) Steglujan and Qtern are contraindicated in patients with severe renal impairment, end stage renal disease (ESRD), or on dialysis.(5-7,9,17) |
REFERENCES
Number |
Reference |
1 |
Invokana prescribing information. Janssen Pharmaceuticals, Inc. July 2023. |
2 |
Farxiga prescribing information. Astra Zeneca. September 2023. |
3 |
Invokamet and Invokamet XR prescribing information. Janssen Pharmaceuticals, Inc. July 2023. |
4 |
Jardiance prescribing information. Boehringer Ingelheim Pharmaceuticals, Inc. September 2023. |
5 |
Xigduo XR prescribing information. AstraZeneca Pharmaceuticals LP. September 2023. |
6 |
Synjardy prescribing information. Boehringer Ingelheim. March 2022. |
7 |
Synjardy XR prescribing information. Boehringer Ingelheim. March 2022. |
8 |
Steglatro prescribing information. Merck & Co, Inc. March 2022. |
9 |
Segluromet prescribing information. Merck Sharp & Dohme Corp. May 2022. |
10 |
American Diabetes Association. Standards of Medical Care in Diabetes-2022. Available at: https://care.diabetesjournals.org/content/45/Supplement_1. |
11 |
Nuha A. ElSayed, et. al, American Diabetes Association, 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes-2023. Diabetes Care 1 January 2023; 46 (Supplement_1): S140-S157. https://doi.org/10.2337/dc23-S009. |
12 |
American Diabetes Association, 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2023. Diabetes Care 1 January 2023; 46 (Supplement_1): S158-S190. https://doi.org/10.2337/dc23-S010. |
13 |
Yancy CW, Jessup M, Bozkurt B, et. al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017;136:e137-e161. Available at: https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000509. |
14 |
Glyxambi prescribing information. Boehringer Ingelheim Pharmaceuticals, Inc and Eli Lilly and Company. March 2022. |
15 |
Qtern prescribing information. Astra Zeneca. September 2023. |
16 |
Steglujan prescribing information. Merck & Co., Inc. June 2022. |
17 |
Trijardy XR prescribing information. Boehringer Ingelheim International GmbH. October 2022. |
18 |
Inpefa Prescribing Information. Lexicon Pharmaceuticals, Inc. May 2023. |
19 |
Brenzavvy prescribing information. TheracosBio, LLC. September 2023. |
POLICY AGENT SUMMARY STEP THERAPY
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Targeted MSC |
Available MSC |
Final Age Limit |
Preferred Status |
Qtern, Steglujan, 2-Step Edit |
||||||
Qtern |
dapagliflozin-saxagliptin tab |
10-5 MG ; 5-5 MG |
M ; N ; O |
N |
|
|
Steglujan |
ertugliflozin-sitagliptin tab |
15-100 MG ; 5-100 MG |
M ; N ; O |
N |
|
|
All other Target Agents 2-Step Edit |
||||||
Brenzavvy |
bexagliflozin tab |
20 MG |
M ; N ; O |
M |
|
|
Inpefa |
sotagliflozin tab |
200 MG ; 400 MG |
M ; N ; O |
N |
|
|
Invokamet ; Invokamet xr |
canagliflozin-metformin hcl tab ; canagliflozin-metformin hcl tab er |
150-1000 MG ; 150-500 MG ; 50-1000 MG ; 50-500 MG |
M ; N ; O |
N |
|
|
Invokana |
canagliflozin tab |
100 MG ; 300 MG |
M ; N ; O |
N |
|
|
Segluromet |
ertugliflozin-metformin hcl tab |
2.5-1000 MG ; 2.5-500 MG ; 7.5-1000 MG ; 7.5-500 MG |
M ; N ; O |
N |
|
|
Steglatro |
ertugliflozin l-pyroglutamic acid tab |
15 MG ; 5 MG |
M ; N ; O |
N |
|
|
POLICY AGENT SUMMARY QUANTITY LIMIT
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
QL Amount |
Dose Form |
Day Supply |
Duration |
Addtl QL Info |
Allowed Exceptions |
Targeted NDCs When Exclusions Exist |
|
|||||||||
Brenzavvy |
bexagliflozin tab |
20 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Farxiga |
dapagliflozin propanediol tab |
10 MG ; 5 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Glyxambi |
empagliflozin-linagliptin tab |
10-5 MG ; 25-5 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Inpefa |
sotagliflozin tab |
200 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Inpefa |
sotagliflozin tab |
400 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Invokamet ; Invokamet xr |
canagliflozin-metformin hcl tab ; canagliflozin-metformin hcl tab er |
150-1000 MG ; 150-500 MG ; 50-1000 MG ; 50-500 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Invokana |
canagliflozin tab |
100 MG ; 300 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Jardiance |
empagliflozin tab |
10 MG ; 25 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Qtern |
dapagliflozin-saxagliptin tab |
10-5 MG ; 5-5 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Segluromet |
ertugliflozin-metformin hcl tab |
2.5-1000 MG ; 2.5-500 MG ; 7.5-1000 MG ; 7.5-500 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Segluromet |
Ertugliflozin-Metformin HCl Tab 2.5-500 MG |
2.5-500 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
Steglatro |
Ertugliflozin L-Pyroglutamic Acid Tab 15 MG (Base Equiv) |
15 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Steglatro |
Ertugliflozin L-Pyroglutamic Acid Tab 5 MG (Base Equiv) |
5 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Steglujan |
ertugliflozin-sitagliptin tab |
15-100 MG ; 5-100 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Synjardy |
empagliflozin-metformin hcl tab |
12.5-1000 MG ; 12.5-500 MG ; 5-1000 MG ; 5-500 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Synjardy xr |
empagliflozin-metformin hcl tab er |
10-1000 MG ; 12.5-1000 MG ; 25-1000 MG ; 5-1000 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Synjardy xr |
Empagliflozin-Metformin HCl Tab ER 24HR 25-1000 MG |
25-1000 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Trijardy xr |
empagliflozin-linaglip-metformin tab er ; empagliflozin-linagliptin-metformin tab er |
10-5-1000 MG ; 12.5-2.5-1000 MG ; 25-5-1000 MG ; 5-2.5-1000 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Trijardy xr |
Empagliflozin-Linaglip-Metformin Tab ER 24HR 12.5-2.5-1000MG |
12.5-2.5-1000 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Trijardy xr |
Empagliflozin-Linagliptin-Metformin Tab ER 24HR 5-2.5-1000MG |
5-2.5-1000 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Xigduo xr |
Dapagliflozin-Metformin HCl Tab ER 24HR 10-1000 MG |
10-1000 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Xigduo xr |
Dapagliflozin-Metformin HCl Tab ER 24HR 10-500 MG |
10-500 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Xigduo xr |
Dapagliflozin-Metformin HCl Tab ER 24HR 2.5-1000 MG |
2.5-1000 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Xigduo xr |
Dapagliflozin-Metformin HCl Tab ER 24HR 5-1000 MG |
5-1000 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Xigduo xr |
Dapagliflozin-Metformin HCl Tab ER 24HR 5-500 MG |
5-500 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
CLIENT SUMMARY – STEP THERAPY
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
Brenzavvy |
bexagliflozin tab |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Inpefa |
sotagliflozin tab |
200 MG ; 400 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Invokamet ; Invokamet xr |
canagliflozin-metformin hcl tab ; canagliflozin-metformin hcl tab er |
150-1000 MG ; 150-500 MG ; 50-1000 MG ; 50-500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Invokana |
canagliflozin tab |
100 MG ; 300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Qtern |
dapagliflozin-saxagliptin tab |
10-5 MG ; 5-5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Segluromet |
ertugliflozin-metformin hcl tab |
2.5-1000 MG ; 2.5-500 MG ; 7.5-1000 MG ; 7.5-500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Steglatro |
ertugliflozin l-pyroglutamic acid tab |
15 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Steglujan |
ertugliflozin-sitagliptin tab |
15-100 MG ; 5-100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
CLIENT SUMMARY – QUANTITY LIMITS
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
Brenzavvy |
bexagliflozin tab |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Farxiga |
dapagliflozin propanediol tab |
10 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Glyxambi |
empagliflozin-linagliptin tab |
10-5 MG ; 25-5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Inpefa |
sotagliflozin tab |
400 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Inpefa |
sotagliflozin tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Invokamet ; Invokamet xr |
canagliflozin-metformin hcl tab ; canagliflozin-metformin hcl tab er |
150-1000 MG ; 150-500 MG ; 50-1000 MG ; 50-500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Invokana |
canagliflozin tab |
100 MG ; 300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Jardiance |
empagliflozin tab |
10 MG ; 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Qtern |
dapagliflozin-saxagliptin tab |
10-5 MG ; 5-5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Segluromet |
ertugliflozin-metformin hcl tab |
2.5-1000 MG ; 2.5-500 MG ; 7.5-1000 MG ; 7.5-500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Segluromet |
Ertugliflozin-Metformin HCl Tab 2.5-500 MG |
2.5-500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Steglatro |
Ertugliflozin L-Pyroglutamic Acid Tab 15 MG (Base Equiv) |
15 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Steglatro |
Ertugliflozin L-Pyroglutamic Acid Tab 5 MG (Base Equiv) |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Steglujan |
ertugliflozin-sitagliptin tab |
15-100 MG ; 5-100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Synjardy |
empagliflozin-metformin hcl tab |
12.5-1000 MG ; 12.5-500 MG ; 5-1000 MG ; 5-500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Synjardy xr |
empagliflozin-metformin hcl tab er |
10-1000 MG ; 12.5-1000 MG ; 25-1000 MG ; 5-1000 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Synjardy xr |
Empagliflozin-Metformin HCl Tab ER 24HR 25-1000 MG |
25-1000 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Trijardy xr |
empagliflozin-linaglip-metformin tab er ; empagliflozin-linagliptin-metformin tab er |
10-5-1000 MG ; 12.5-2.5-1000 MG ; 25-5-1000 MG ; 5-2.5-1000 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Trijardy xr |
Empagliflozin-Linaglip-Metformin Tab ER 24HR 12.5-2.5-1000MG |
12.5-2.5-1000 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Trijardy xr |
Empagliflozin-Linagliptin-Metformin Tab ER 24HR 5-2.5-1000MG |
5-2.5-1000 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xigduo xr |
Dapagliflozin-Metformin HCl Tab ER 24HR 10-1000 MG |
10-1000 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xigduo xr |
Dapagliflozin-Metformin HCl Tab ER 24HR 10-500 MG |
10-500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xigduo xr |
Dapagliflozin-Metformin HCl Tab ER 24HR 2.5-1000 MG |
2.5-1000 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xigduo xr |
Dapagliflozin-Metformin HCl Tab ER 24HR 5-1000 MG |
5-1000 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xigduo xr |
Dapagliflozin-Metformin HCl Tab ER 24HR 5-500 MG |
5-500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
STEP THERAPY CLINICAL CRITERIA FOR APPROVAL
Module |
Clinical Criteria for Approval |
2-Step Edit: All Other Target Agents |
Target Agent(s) Brenzavvy, bexagliflozin
Length of Approval: 12 months NOTE: If Quantity Limit applies, please refer to Quantity Limit Criteria. *Step therapy requirement may not apply if a prior health plan paid for the medication - documentation of a paid claim may be required. |
2-Step Edit: Qtern, Steglujan |
Target Agent(s) Qtern (dapagliflozin/saxagliptin) Target Agent(s)-Qtern, Steglujan will be approved when ONE of the following is met:
Length of Approval: 12 months NOTE: If Quantity Limit applies, please refer to Quantity Limit Criteria. *Step therapy requirement may not apply if a prior health plan paid for the medication - documentation of a paid claim may be required. |
QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL
Module |
Clinical Criteria for Approval |
|
Quantity Limit for the Target Agent(s) will be approved when ONE of the following is met:
Length of Approval: up to 12 months |
This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.
Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.
ALBP _ Commercial _ OCReg _ Sodium-glucose_Co-transporter_(SGLT)_Inhibitors_and_Combinations_STQL _ProgSum_ 04-01-2024