Metformin hydrochloride 750 MG — Blue Cross Blue Shield of Montana
another FDA labeled indication for the requested agent and route of administration
Preferred products
- Metformin HCl Tab ER 24HR Osmotic 500 MG
- Metformin HCl Tab ER 24HR Osmotic 1000 MG
Initial criteria
- The patient has a diagnosis of type 2 diabetes mellitus OR another FDA labeled indication for the requested agent and route of administration OR another indication that is supported in compendia for the requested agent and route of administration AND
- ONE of the following: the request is for a BCBS IL Fully Insured, HIM, or Non-ERISA ASO/Self-insured Municipalities/Counties member OR the patient is currently being treated with and stable on the requested agent OR the patient has tried and had an inadequate response to ONE non-targeted generic metformin product OR ONE non-targeted generic metformin product was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event OR the patient has an intolerance or hypersensitivity to ONE non-targeted generic metformin product not expected to occur with the requested agent OR the patient has an FDA labeled contraindication to ALL non-targeted generic metformin products not expected to occur with the requested agent OR ONE non-targeted generic metformin product is expected to be ineffective or cause adherence barriers, worsen a comorbid condition, decrease functional ability, or cause harm OR ONE non-targeted generic metformin product is not in the patient’s best interest based on medical necessity OR the patient has tried another prescription drug in the same class as metformin that was discontinued due to inefficacy or adverse event OR if the patient has diabetes, the requested agent is medically necessary and appropriate for the patient AND
- The patient does NOT have any FDA labeled contraindication(s) to the requested agent