Diabetes, DPP-4 Inhibitors
PDL Reference Documents
Newsletters
- September 2020 - Cardiovascular Outcomes Associated with Newer Therapy Classes for Type 2 Diabetes Mellitus
- September 2018 - Management Strategies for Patients with Prediabetes
- March 2016 - Antidiabetic Treatments and Cardiovascular Implications
- February 2016 - 2015 in Review: Relevant Safety Updates and Ongoing Safety Concerns
- October 2013 - Updates and Comparisons of Type 2 Diabetes Treatment Guidelines
- June 2012 - Can The Diabetic War Be Fought By Aggressive Blood Pressure Control?
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.
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 45802021172 | ALOGLIPTIN-METFORMIN | alogliptin benz/metformin HCl | TABLET | 12.5 mg-1,000 mg | N | Y | PA Document |
| 64764033760 | KAZANO | alogliptin benz/metformin HCl | TABLET | 12.5 mg-1,000 mg | N | Y | PA Document |
| 45802016972 | ALOGLIPTIN-METFORMIN | alogliptin benz/metformin HCl | TABLET | 12.5 mg-500 mg | N | Y | PA Document |
| 64764033560 | KAZANO | alogliptin benz/metformin HCl | TABLET | 12.5 mg-500 mg | N | Y | PA Document |
| 45802026065 | ALOGLIPTIN-PIOGLITAZONE | alogliptin benz/pioglitazone | TABLET | 12.5 mg-30 mg | N | Y | PA Document |
| 45802035165 | ALOGLIPTIN-PIOGLITAZONE | alogliptin benz/pioglitazone | TABLET | 25 mg-15 mg | N | Y | PA Document |
| 45802040265 | ALOGLIPTIN-PIOGLITAZONE | alogliptin benz/pioglitazone | TABLET | 25 mg-30 mg | N | Y | PA Document |
| 64764025303 | OSENI | alogliptin benz/pioglitazone | TABLET | 25 mg-30 mg | N | Y | PA Document |
| 45802049965 | ALOGLIPTIN-PIOGLITAZONE | alogliptin benz/pioglitazone | TABLET | 25 mg-45 mg | N | Y | PA Document |
| 45802010365 | ALOGLIPTIN | alogliptin benzoate | TABLET | 12.5 mg | N | Y | PA Document |
| 64764012530 | NESINA | alogliptin benzoate | TABLET | 12.5 mg | N | Y | PA Document |
| 45802015065 | ALOGLIPTIN | alogliptin benzoate | TABLET | 25 mg | N | Y | PA Document |
| 64764025030 | NESINA | alogliptin benzoate | TABLET | 25 mg | N | Y | PA Document |
| 45802008765 | ALOGLIPTIN | alogliptin benzoate | TABLET | 6.25 mg | N | Y | PA Document |
| 00597014030 | TRADJENTA | linagliptin | TABLET | 5 mg | N | Y | PA Document |
| 00597014061 | TRADJENTA | linagliptin | TABLET | 5 mg | N | Y | PA Document |
| 00597014070 | TRADJENTA | linagliptin | TABLET | 5 mg | N | Y | PA Document |
| 00597014090 | TRADJENTA | linagliptin | TABLET | 5 mg | N | Y | PA Document |
| 00597027073 | JENTADUETO XR | linagliptin/metformin HCl | TAB BP 24H | 2.5 mg-1,000 mg | N | Y | PA Document |
| 00597027094 | JENTADUETO XR | linagliptin/metformin HCl | TAB BP 24H | 2.5 mg-1,000 mg | N | Y | PA Document |
| 00597027533 | JENTADUETO XR | linagliptin/metformin HCl | TAB BP 24H | 5 mg-1,000 mg | N | Y | PA Document |
| 00597027581 | JENTADUETO XR | linagliptin/metformin HCl | TAB BP 24H | 5 mg-1,000 mg | N | Y | PA Document |
| 00597014818 | JENTADUETO | linagliptin/metformin HCl | TABLET | 2.5 mg-1,000 mg | N | Y | PA Document |
| 00597014860 | JENTADUETO | linagliptin/metformin HCl | TABLET | 2.5 mg-1,000 mg | N | Y | PA Document |
| 00597014618 | JENTADUETO | linagliptin/metformin HCl | TABLET | 2.5 mg-500 mg | N | Y | PA Document |
| 00597014660 | JENTADUETO | linagliptin/metformin HCl | TABLET | 2.5 mg-500 mg | N | Y | PA Document |
| 00597014718 | JENTADUETO | linagliptin/metformin HCl | TABLET | 2.5 mg-850 mg | N | Y | PA Document |
| 00597014760 | JENTADUETO | linagliptin/metformin HCl | TABLET | 2.5 mg-850 mg | N | Y | PA Document |
| 00310610030 | ONGLYZA | saxagliptin HCl | TABLET | 2.5 mg | Y | Y | PA Document |
| 00378470577 | SAXAGLIPTIN HCL | saxagliptin HCl | TABLET | 2.5 mg | Y | Y | PA Document |
| 00378470593 | SAXAGLIPTIN HCL | saxagliptin HCl | TABLET | 2.5 mg | Y | Y | PA Document |
| 65162005903 | SAXAGLIPTIN HCL | saxagliptin HCl | TABLET | 2.5 mg | Y | Y | PA Document |
| 65862082530 | SAXAGLIPTIN HCL | saxagliptin HCl | TABLET | 2.5 mg | Y | Y | PA Document |
| 65862082590 | SAXAGLIPTIN HCL | saxagliptin HCl | TABLET | 2.5 mg | Y | PA Document | |
| 68462072630 | SAXAGLIPTIN HCL | saxagliptin HCl | TABLET | 2.5 mg | Y | Y | PA Document |
| 68462072690 | SAXAGLIPTIN HCL | saxagliptin HCl | TABLET | 2.5 mg | Y | Y | PA Document |
| 00310610530 | ONGLYZA | saxagliptin HCl | TABLET | 5 mg | Y | Y | PA Document |
| 00310610590 | ONGLYZA | saxagliptin HCl | TABLET | 5 mg | Y | Y | PA Document |
| 00378470677 | SAXAGLIPTIN HCL | saxagliptin HCl | TABLET | 5 mg | Y | Y | PA Document |
| 00378470693 | SAXAGLIPTIN HCL | saxagliptin HCl | TABLET | 5 mg | Y | Y | PA Document |
| 65162006003 | SAXAGLIPTIN HCL | saxagliptin HCl | TABLET | 5 mg | Y | Y | PA Document |
| 65862082630 | SAXAGLIPTIN HCL | saxagliptin HCl | TABLET | 5 mg | Y | Y | PA Document |
| 65862082690 | SAXAGLIPTIN HCL | saxagliptin HCl | TABLET | 5 mg | Y | PA Document | |
| 68462072730 | SAXAGLIPTIN HCL | saxagliptin HCl | TABLET | 5 mg | Y | Y | PA Document |
| 68462072790 | SAXAGLIPTIN HCL | saxagliptin HCl | TABLET | 5 mg | Y | Y | PA Document |
| 00310612560 | KOMBIGLYZE XR | saxagliptin HCl/metformin HCl | TBMP 24HR | 2.5 mg-1,000 mg | N | Y | PA Document |
| 00378817691 | SAXAGLIPTIN-METFORMIN ER | saxagliptin HCl/metformin HCl | TBMP 24HR | 2.5 mg-1,000 mg | N | Y | PA Document |
| 43598061860 | SAXAGLIPTIN-METFORMIN ER | saxagliptin HCl/metformin HCl | TBMP 24HR | 2.5 mg-1,000 mg | N | Y | PA Document |
| 00310614530 | KOMBIGLYZE XR | saxagliptin HCl/metformin HCl | TBMP 24HR | 5 mg-1,000 mg | N | Y | PA Document |
| 00378817793 | SAXAGLIPTIN-METFORMIN ER | saxagliptin HCl/metformin HCl | TBMP 24HR | 5 mg-1,000 mg | N | Y | PA Document |
| 43598061930 | SAXAGLIPTIN-METFORMIN ER | saxagliptin HCl/metformin HCl | TBMP 24HR | 5 mg-1,000 mg | N | Y | PA Document |
| 00310613530 | KOMBIGLYZE XR | saxagliptin HCl/metformin HCl | TBMP 24HR | 5 mg-500 mg | N | Y | PA Document |
| 00378817593 | SAXAGLIPTIN-METFORMIN ER | saxagliptin HCl/metformin HCl | TBMP 24HR | 5 mg-500 mg | N | Y | PA Document |
| 43598062030 | SAXAGLIPTIN-METFORMIN ER | saxagliptin HCl/metformin HCl | TBMP 24HR | 5 mg-500 mg | N | Y | PA Document |
| 70710190103 | SITAGLIPTIN | sitagliptin | TABLET | 100 mg | N | Y | PA Document |
| 70710190109 | SITAGLIPTIN | sitagliptin | TABLET | 100 mg | N | Y | PA Document |
| 70710124203 | ZITUVIO | sitagliptin | TABLET | 100 mg | N | Y | PA Document |
| 70710189903 | SITAGLIPTIN | sitagliptin | TABLET | 25 mg | N | Y | PA Document |
| 70710189909 | SITAGLIPTIN | sitagliptin | TABLET | 25 mg | N | Y | PA Document |
| 70710124003 | ZITUVIO | sitagliptin | TABLET | 25 mg | N | Y | PA Document |
| 70710190003 | SITAGLIPTIN | sitagliptin | TABLET | 50 mg | N | Y | PA Document |
| 70710190009 | SITAGLIPTIN | sitagliptin | TABLET | 50 mg | N | Y | PA Document |
| 70710124103 | ZITUVIO | sitagliptin | TABLET | 50 mg | N | Y | PA Document |
| 24338001701 | BRYNOVIN | sitagliptin HCl | SOLUTION | 25 mg/mL | N | Y | PA Document |
| 00006057761 | JANUMET | sitagliptin phos/metformin HCl | TABLET | 50 mg-1,000 mg | Y | Y | PA Document |
| 00006057762 | JANUMET | sitagliptin phos/metformin HCl | TABLET | 50 mg-1,000 mg | Y | Y | PA Document |
| 00006057782 | JANUMET | sitagliptin phos/metformin HCl | TABLET | 50 mg-1,000 mg | Y | Y | PA Document |
| 00006057561 | JANUMET | sitagliptin phos/metformin HCl | TABLET | 50 mg-500 mg | Y | Y | PA Document |
| 00006057562 | JANUMET | sitagliptin phos/metformin HCl | TABLET | 50 mg-500 mg | Y | Y | PA Document |
| 00006057582 | JANUMET | sitagliptin phos/metformin HCl | TABLET | 50 mg-500 mg | Y | Y | PA Document |
| 00006008131 | JANUMET XR | sitagliptin phos/metformin HCl | TBMP 24HR | 100 mg-1,000 mg | N | Y | PA Document |
| 00006008154 | JANUMET XR | sitagliptin phos/metformin HCl | TBMP 24HR | 100 mg-1,000 mg | N | Y | PA Document |
| 00006008182 | JANUMET XR | sitagliptin phos/metformin HCl | TBMP 24HR | 100 mg-1,000 mg | N | Y | PA Document |
| 00006008061 | JANUMET XR | sitagliptin phos/metformin HCl | TBMP 24HR | 50 mg-1,000 mg | N | Y | PA Document |
| 00006008062 | JANUMET XR | sitagliptin phos/metformin HCl | TBMP 24HR | 50 mg-1,000 mg | N | Y | PA Document |
| 00006008082 | JANUMET XR | sitagliptin phos/metformin HCl | TBMP 24HR | 50 mg-1,000 mg | N | Y | PA Document |
| 00006007861 | JANUMET XR | sitagliptin phos/metformin HCl | TBMP 24HR | 50 mg-500 mg | N | Y | PA Document |
| 00006007862 | JANUMET XR | sitagliptin phos/metformin HCl | TBMP 24HR | 50 mg-500 mg | N | Y | PA Document |
| 00006007882 | JANUMET XR | sitagliptin phos/metformin HCl | TBMP 24HR | 50 mg-500 mg | N | Y | PA Document |
| 00006027701 | JANUVIA | sitagliptin phosphate | TABLET | 100 mg | Y | Y | PA Document |
| 00006027728 | JANUVIA | sitagliptin phosphate | TABLET | 100 mg | Y | Y | PA Document |
| 00006027731 | JANUVIA | sitagliptin phosphate | TABLET | 100 mg | Y | Y | PA Document |
| 00006027754 | JANUVIA | sitagliptin phosphate | TABLET | 100 mg | Y | Y | PA Document |
| 00006027782 | JANUVIA | sitagliptin phosphate | TABLET | 100 mg | Y | Y | PA Document |
| 00006022101 | JANUVIA | sitagliptin phosphate | TABLET | 25 mg | Y | Y | PA Document |
| 00006022128 | JANUVIA | sitagliptin phosphate | TABLET | 25 mg | Y | Y | PA Document |
| 00006022131 | JANUVIA | sitagliptin phosphate | TABLET | 25 mg | Y | Y | PA Document |
| 00006022154 | JANUVIA | sitagliptin phosphate | TABLET | 25 mg | Y | Y | PA Document |
| 00006011201 | JANUVIA | sitagliptin phosphate | TABLET | 50 mg | Y | Y | PA Document |
| 00006011228 | JANUVIA | sitagliptin phosphate | TABLET | 50 mg | Y | Y | PA Document |
| 00006011231 | JANUVIA | sitagliptin phosphate | TABLET | 50 mg | Y | Y | PA Document |
| 00006011254 | JANUVIA | sitagliptin phosphate | TABLET | 50 mg | Y | Y | PA Document |
| 70710198706 | SITAGLIPTIN-METFORMIN | sitagliptin/metformin HCl | TABLET | 50 mg-1,000 mg | N | Y | PA Document |
| 70710178706 | ZITUVIMET | sitagliptin/metformin HCl | TABLET | 50 mg-1,000 mg | N | Y | PA Document |
| 70710198606 | SITAGLIPTIN-METFORMIN | sitagliptin/metformin HCl | TABLET | 50 mg-500 mg | N | Y | PA Document |
| 70710178606 | ZITUVIMET | sitagliptin/metformin HCl | TABLET | 50 mg-500 mg | N | Y | PA Document |
| 70710203803 | SITAGLIPTIN-METFORMIN ER | sitagliptin/metformin HCl | TBMP 24HR | 100 mg-1,000 mg | N | Y | PA Document |
| 70710180603 | ZITUVIMET XR | sitagliptin/metformin HCl | TBMP 24HR | 100 mg-1,000 mg | N | Y | PA Document |
| 70710203706 | SITAGLIPTIN-METFORMIN ER | sitagliptin/metformin HCl | TBMP 24HR | 50 mg-1,000 mg | N | Y | PA Document |
| 70710180506 | ZITUVIMET XR | sitagliptin/metformin HCl | TBMP 24HR | 50 mg-1,000 mg | N | Y | PA Document |
| 70710203606 | SITAGLIPTIN-METFORMIN ER | sitagliptin/metformin HCl | TBMP 24HR | 50 mg-500 mg | N | Y | PA Document |
| 70710180406 | ZITUVIMET XR | sitagliptin/metformin HCl | TBMP 24HR | 50 mg-500 mg | N | Y | PA Document |