Microsoft word - diabetic oral step.doc

Step Therapy/Prior Authorization Criteria

Drug (For Commercial Members): ActoplusMet XR, Avandia, Avandamet, Avandaryl,
Duetact, Fortamet, Glumetza, Invokana, Kazano, Kombiglyze XR, Nesina, Onglyza, Oseni
Drug (For Freedom Formulary Members): ActoplusMet XR, Duetact, Invokana, Kazano,
Nesina, Oseni
P&T Reviewed: 3/08, 6/08, 9/08, 9/09, 9/10, 12/11, 10/13
Last Revised: 9/08, 12/09, 12/10, 5/11, 12/11, 9/12, 3/13, 4/13, 10/13

FDA Labeled indications:
ActoplusMet XR, Avandia, Avandamet, Avandaryl, Cycloset, Duetact, Prandimet- These agents
are approved for the treatment of Type 2 diabetes in combination with other agents or alone as an
adjunct to diet and exercise to improve glycemic control
Fortamet/Glumetza- These agents are an extended-release formulation of metformin indicated as
an adjunct to diet and exercise to improve glycemic control in patients 18 years of age and older
with type diabetes.
Invokana/Kazano/Kombiglyze XR/Nesina/Onglyza/Oseni—These agents are indicated as an
adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.
Criteria:
ConnectiCare considers ActoplusMet XR, Duetact or Invokana (and Avandia, Avandamet,
Avandaryl for Commercial Members only) to be medically necessary for patients who meet
the following criteria:

1. Patient has a diagnosis of diabetes mellitus type 2
AND
2. Patient has a documented intolerance to, contraindication, or treatment failure to an adequate
Contraindications to metformin include:  Impaired renal function (serum creatinine >1.5mg/dL in males, >1.4 mg/dL in females  Diseases that predispose to acidosis (congestive heart failure, liver failure, major surgery)  Alcohol abuse Note: If a claim can not be found in your prescription history a copy of the physician chart note documenting the intolerance must be supplied for review Note: Avandia, Avandamet, and Avandaryl and not available to Freedom Formulary members Criteria for Fortamet and Glumetza (Commercial Members only):
ConnectiCare considers Fortamet and Glumetza to be medically necessary for patients who
meet the following criteria:
1. Patient has a diagnosis of diabetes mellitus type 2 2. Patient has a documented intolerance to, contraindication, or treatment failure to an
Note: If a claim can not be found in your prescription history a copy of the physician chart note
documenting the intolerance must be supplied for review
Note: Glumetza and Fortamet are not available to Freedom Formulary members
For Commercial members only:
Criteria for Nesina, Onglyza, Oseni, Kazano, Kombiglyze XR:
ConnectiCare considers these agents to be medically necessary for patients who meet the
following criteria:
1. Patient has a diagnosis of diabetes mellitus type 2 2. Patient has a documented intolerance to, contraindication, or treatment failure to an 3. Patient has a documented intolerance to, or treatment failure of, Januvia, Janumet, Note: If a claim cannot be found in your prescription history a copy of the physician chart note
documenting the intolerance must be supplied for review
Note: Kombiglyze XR and Onglyza are not available to Freedom Formulary members

For Freedom Formulary members only:
Criteria for Nesina, Oseni, and Kazano:
ConnectiCare considers these agents to be medically necessary for patients who meet the
following criteria:
1. Patient has a diagnosis of diabetes mellitus type 2 2. Patient has a documented intolerance to, contraindication, or treatment failure to an 3. Patient has a documented intolerance to, or treatment failure of, Tradjenta or Jentadueto Note: If a claim cannot be found in your prescription history a copy of the physician chart note documenting the intolerance must be supplied for review Prior Authorization and Limitations:
If the above criteria are met initial authorization will be given for 1 year.
The above criteria is based on the following reference(s):
1. Nathan DM, Buse JB, Davidson MB, et al. Management of hyperglycemia on type 2 diabetes: a
consensus algorithm for the initiation and adjustment of therapy. Diabetes Care 2006;29:1963-72.
2.The Pharmacist’s Letter. June 2007 Volume23 #230670.
3. The Medical Letter. Drugs for Diabetes August 2005 Vol.3 Issue 36.
4. Duetact full prescribing information. Deerfield IL. Takeda Pharmaceuticals.
5. Avandia full prescribing information. Research Triangle Park. GlaxoSmithKline
6. Avandamet full prescribing information. Research Triangle Park. GlaxoSmithKline
7. Avandaryl full prescribing information. Research Triangle Park. GlaxoSmithKline
8. Glumetza full prescribing information. Menlo Park, CA. DepoMed Inc.
9. Fortamet full prescribing information. Atlanta, GA. Sciele Pharma Inc.
10. Tradjenta full prescribing information, Ingelheim, Germany, Boehringer Ingelheim Inc.
11. Facts & Comparisons Online, accessed April 2013
12. Invokana full prescribing information, Titusville, NJ, Janssen Pharmaceuticals

Source: http://www.connecticare.com/providers/PDFs/Pharmacy/Diabetic%20Oral%20Step.pdf