Pharmacy Prior Authorization Criteria

Diabetic Agents

For diagnosis of Type 2 diabetes mellitus
Indicated as an adjunct to diet and exercise to improve glycemic control in adults and pediatric patients 10 years of age and older with type 2 diabetes mellitus.

For diagnosis of Type 2 diabetes mellitus
Indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Limitations of use: 1) Cycloset should not be used to treat type 1 diabetes or diabetic ketoacidosis; 2) Limited efficacy data in combination with thiazolidinediones; 3) Efficacy has not been confirmed in combination with insulin.

Step Therapy

Length of Approval: 12 Month(s)

Requested drug is being used for a Food and Drug Administration (FDA)-approved indication

AND

Trial and failure (of a minimum 30-day supply), intolerance, or contraindication to one of the following generics:

2024-06-20, 2023-06-22, 2022-06-16, 2021-08-02, 2021-05-21, 2020-04-29, 2020-03-02

2024-06-20: 2024 annual review: no changes.
2023-06-22: Annual review: added “(of a minimum 30-day supply)” to to trial and failure requirement to match coding, removed obsolete Riomet ER and Avandia products.
2022-06-16: Annual review: Removed obsolete Actoplus Met XR. Removed Actoplus Met as targeted products to align with coding. Added criterion "Requested drug is being used for a Food and Drug Administration (FDA)-approved indication."
2021-08-02: Annual review: background updates, no changes to clinical criteria
2021-05-21: Annual review: background updates, no changes to clinical criteria
2020-04-29: annual review no changes to clinical criteria
2020-03-02: Added Riomet ER as a target in existing step