Diabetes, Miscellaneous Antidiabetic Agents

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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
metformin HCl METFORMIN HCL ER TAB ER 24H Y    
metformin HCl GLUCOPHAGE XR TAB ER 24H Y    
metformin HCl METFORMIN HCL TABLET Y    
metformin HCl GLUCOPHAGE TABLET Y    
acarbose PRECOSE TABLET N    
acarbose ACARBOSE TABLET N    
glipizide/metformin HCl GLIPIZIDE-METFORMIN TABLET N    
glyburide/metformin HCl GLYBURIDE-METFORMIN HCL TABLET N    
glyburide/metformin HCl GLUCOVANCE TABLET N    
metformin HCl RIOMET SOLUTION N    
metformin HCl METFORMIN HCL ER TAB ER 24 N    
metformin HCl FORTAMET TAB ER 24 N    
metformin HCl METFORMIN HCL ER TABERGR24H N    
metformin HCl GLUMETZA TABERGR24H N    
miglitol GLYSET TABLET N    
miglitol MIGLITOL TABLET N    
nateglinide STARLIX TABLET N    
nateglinide NATEGLINIDE TABLET N    
pramlintide acetate SYMLINPEN 60 PEN INJCTR N    
pramlintide acetate SYMLINPEN 120 PEN INJCTR N    
repaglinide REPAGLINIDE TABLET N    
repaglinide PRANDIN TABLET N    
repaglinide/metformin HCl REPAGLINIDE-METFORMIN HCL TABLET N