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 ALOGLIPTIN-METFORMIN TABLET N PA Document  
alogliptin benz/metformin HCl KAZANO TABLET N PA Document  
alogliptin benz/pioglitazone ALOGLIPTIN-PIOGLITAZONE TABLET N PA Document  
alogliptin benz/pioglitazone OSENI TABLET N PA Document  
alogliptin benzoate ALOGLIPTIN TABLET N PA Document  
alogliptin benzoate NESINA TABLET N PA Document  
dapagliflozin/saxagliptin HCl QTERN TABLET N    
empagliflozin/linagliptin GLYXAMBI TABLET N    
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