Pharmacy Prior Authorization Criteria

Glumetza (metformin ER tablets)

Indications for Prior Authorization

Glumetza (metformin ER tablets)

• For diagnosis of Type 2 Diabetes
  Indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.

Criteria

Brand Glumetza, Generic metformin ER 24 HR tablet [Generic Glumetza]*

*This guideline applies to all medically accepted indications.

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• One of the following:
• Both of the following:
• History of greater than or equal to 12 week trial of metformin extended-release (generic Glucophage XR) [A]
AND
• Documented history of an inadequate response to metformin extended-release (generic Glucophage XR) as evidenced by Hemoglobin A1c level above patient's goal
OR
• Documented history of intolerance to metformin extended-release (generic Glucophage XR) which is unable to be resolved with attempts to minimize the adverse effects where appropriate (e.g., dose reduction)
AND
• One of the following:
• Both of the following:
• History of greater than or equal to 12 week trial of metformin immediate-release
AND
• Documented history of an inadequate response to metformin immediate-release as evidenced by Hemoglobin A1c level above patient's goal
OR
• Documented history of intolerance to metformin immediate-release which is unable to be resolved with attempts to minimize the adverse effects where appropriate (e.g., dose reduction)

Brand Glumetza, Generic metformin ER 24 HR tablet [Generic Glumetza]*

*This guideline applies to all medically accepted indications.

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient has experienced an objective response to therapy demonstrated by an improvement in HbA1c from baseline

P & T Revisions

2024-08-15, 2024-06-20, 2023-06-22, 2022-06-17, 2021-08-02, 2021-05-24, 2021-05-19, 2020-04-29

References

1. Glumetza Prescribing Information. Salix Pharmaceuticals. Bridgewater, NJ. March 2024.

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Revision History

• 2024-08-15: Added operational note per PA request.
• 2024-06-20: 2024 annual review: no criteria changes.
• 2023-06-22: Annual review - no changes.
• 2022-06-17: Annual review: no changes.
• 2021-08-02: Annual review: updated indication to align with PI - no changes to criteria or clinical intent, updated references
• 2021-05-24: Annual review: updated indication to align with PI - no changes to criteria or clinical intent, updated references
• 2021-05-19: Addition of EHB formulary to guideline, no changes to criteria
• 2020-04-29: annual review no changes

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