Metformin HCl Tab ER 24HR Osmotic 500 mg — Blue Cross Blue Shield of Illinois

Initial criteria

• 1. ONE of the following: (A) Patient has a diagnosis of type 2 diabetes mellitus OR (B) Patient has another FDA labeled indication for the requested agent and route of administration OR (C) Patient has another indication that is supported in compendia for the requested agent and route of administration
• AND 2. ONE of the following: (A) Request is for a BCBS IL Fully Insured, HIM, or Non‑ERISA ASO/Self‑insured Municipalities/Counties member OR (B) Patient is currently being treated with the requested agent and is currently stable on the requested agent OR (C) Patient has tried and had an inadequate response to ONE non‑targeted generic metformin product OR (D) ONE non‑targeted generic metformin product was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event OR (E) Patient has an intolerance or hypersensitivity to ONE non‑targeted generic metformin product that is not expected to occur with the requested agent OR (F) Patient has an FDA labeled contraindication to ALL non‑targeted generic metformin products that is not expected to occur with the requested agent OR (G) ONE non‑targeted generic metformin product is expected to be ineffective based on the known clinical characteristics of the patient and the prescription drug; OR cause a significant barrier to adherence; OR worsen a comorbid condition; OR decrease functional ability in daily activities; OR cause an adverse reaction or cause physical or mental harm OR (H) ONE non‑targeted generic metformin product is not in the best interest of the patient based on medical necessity OR (I) Patient has tried another prescription drug in the same pharmacologic class or with the same mechanism of action as ONE non‑targeted generic metformin product and that drug was discontinued due to lack of efficacy, diminished effect, or an adverse event OR (J) If the patient has diabetes, then the requested agent is medically necessary and appropriate for the patient
• AND 3. Patient does NOT have any FDA labeled contraindication(s) to the requested agent