Metformin hydrochloride 750 mg — Blue Cross Blue Shield of Oklahoma

Initial criteria

• ONE of the following: A. The patient has a diagnosis of type 2 diabetes mellitus OR B. The patient has another FDA labeled indication for the requested agent and route of administration OR C. The patient has another indication that is supported in compendia for the requested agent and route of administration
• AND ONE of the following: A. The request is for a BCBS IL Fully Insured, HIM, or Non‑ERISA ASO/Self‑insured Municipalities/Counties member OR B. The patient is currently being treated with the requested agent and is currently stable on it OR C. The 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, effectiveness, diminished effect, or adverse event OR E. The 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. The 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 clinical characteristics, cause adherence barrier, worsen a comorbid condition, decrease functional ability, cause adverse reaction or harm OR H. ONE non‑targeted generic metformin product is not in the best interest of the patient based on medical necessity OR I. The patient has tried another prescription drug in the same pharmacologic class or mechanism as ONE non‑targeted generic metformin product and it was discontinued due to lack of efficacy, diminished effect, or adverse event OR J. 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