Diabetes, DPP-4 Inhibitors

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
SITAGLIPTIN PHOS/METFORMIN HCL JANUMET TABLET Y PA Document  
SITAGLIPTIN PHOSPHATE JANUVIA TABLET Y PA Document  
ALOGLIPTIN BENZ/METFORMIN HCL KAZANO TABLET N PA Document  
ALOGLIPTIN BENZ/METFORMIN HCL ALOGLIPTIN-METFORMIN TABLET N PA Document  
ALOGLIPTIN BENZ/PIOGLITAZONE OSENI TABLET N PA Document  
ALOGLIPTIN BENZ/PIOGLITAZONE ALOGLIPTIN-PIOGLITAZONE TABLET N PA Document  
ALOGLIPTIN BENZOATE NESINA TABLET N PA Document  
ALOGLIPTIN BENZOATE ALOGLIPTIN TABLET N PA Document  
LINAGLIPTIN TRADJENTA TABLET N PA Document Apr 26, 2012
LINAGLIPTIN/METFORMIN HCL JENTADUETO XR TAB BP 24H N PA Document  
LINAGLIPTIN/METFORMIN HCL JENTADUETO TABLET N PA Document  
SAXAGLIPTIN HCL ONGLYZA TABLET N PA Document  
SAXAGLIPTIN HCL/METFORMIN HCL KOMBIGLYZE XR TBMP 24HR N PA Document  
SITAGLIPTIN PHOS/METFORMIN HCL JANUMET XR TBMP 24HR N PA Document