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 ACARBOSE TABLET N    
ACARBOSE PRECOSE TABLET N    
GLIPIZIDE/METFORMIN HCL GLIPIZIDE-METFORMIN TABLET N    
GLYBURIDE/METFORMIN HCL GLUCOVANCE TABLET N    
GLYBURIDE/METFORMIN HCL GLYBURIDE-METFORMIN HCL TABLET N    
METFORMIN HCL RIOMET SOLUTION N    
METFORMIN HCL FORTAMET TAB ER 24 N    
METFORMIN HCL METFORMIN HCL ER TAB ER 24 N    
METFORMIN HCL METFORMIN HCL ER TABERGR24H N    
METFORMIN HCL GLUMETZA TABERGR24H N    
MIGLITOL MIGLITOL TABLET N    
MIGLITOL GLYSET TABLET N    
NATEGLINIDE NATEGLINIDE TABLET N    
NATEGLINIDE STARLIX 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