FORTAMET ER (metformin)

FORTAMET ER (metformin)

SELF-ADMINISTRATION

Indication for Prior Authorization: 

Indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus

Coverage Criteria:

1. For diagnosis of type 2 diabetes mellitus

• Dose does not exceed 2 g per day, AND
• Documented diagnosis of type 2 diabetes mellitus, AND
• Trial and failure of metformin extended-release (Glucophage XR) with documentation supporting for treatment failure that would not be expected with metformin extended-release OSM (note: treatment failure due to ineffectiveness of metformin extended-release is not considered towards metformin extended-release OSM formulation prior authorization approval)

Reauthorization Criteria:

For diagnosis of type 2 diabetes mellitus

• Dose does not exceed 2 g per day, AND
• Documentation of a positive clinical response to therapy

Coverage Duration:

• Initial: 1 year
• Reauthorization: 1 year

Dosing:

• Maximum: 2 g per day

Authorization is not covered for the following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Policy Updates:

• 10/19/2021 – Updated policy to remove IR formulations
• 2/16/21- Annual review.  Developed criteria for high-cost Metformin ER (generic to Fortamet) and format updated.  

References:

• Fortamet Prescribing Information. Actavis Laboratories FL, Inc. Fort Lauderdale, FL. November 2018
• Glumetza Prescribing Information. Salix Pharmaceuticals. Bridgewater, NJ.  November 2018