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Onglyza (saxagliptin) — Blue Cross Blue Shield of Oklahoma

type 2 diabetes mellitus

Preferred products

  • Alogliptin
  • Alogliptin/metformin
  • Alogliptin/pioglitazone
  • Brynovin (sitagliptin)
  • Jentadueto (linagliptin/metformin)
  • Jentadueto XR (linagliptin/metformin ER)
  • Tradjenta (linagliptin)

Initial criteria

  • 1. ONE of the following:
  • A. The patient is currently being treated with the requested agent AND the patient is currently stable on the requested agent OR
  • B. The patient has tried and had an inadequate response to a preferred DPP-4 inhibitor agent OR
  • C. A preferred DPP-4 inhibitor was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event OR
  • D. The patient has an intolerance or hypersensitivity to sitagliptin that is not expected to occur with the requested agent OR
  • E. The patient has an FDA labeled contraindication to sitagliptin that is not expected to occur with the requested agent OR
  • F. A preferred DPP-4 inhibitor is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the prescription drug; OR cause a significant barrier to the patient’s adherence of care; OR worsen a comorbid condition; OR decrease the patient’s ability to achieve or maintain reasonable functional ability in performing daily activities; OR cause an adverse reaction or cause physical or mental harm OR
  • G. A preferred DPP-4 inhibitor is not in the best interest of the patient based on medical necessity OR
  • H. The patient has tried another prescription drug in the same pharmacologic class or with the same mechanism of action as a preferred DPP-4 inhibitor and that prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event OR
  • I. The requested agent is medically necessary and appropriate for the patient AND
  • 2. The patient will NOT be using the requested agent in combination with another DPP-4 inhibitor/combination agent (e.g., Brynovin, Januvia, Janumet, Janumet XR, Jentadueto, Jentadueto XR, Kazano, Kombiglyze XR, Nesina, Onglyza, Oseni, Tradjenta, Zituvio, Zituvimet, Zituvimet XR) for the requested indication AND
  • 3. The patient will NOT be using the requested agent in combination with a GLP-1 or GLP-1/GIP receptor agonist (e.g., Saxenda, Wegovy, Zepbound, Adlyxin, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza)

Approval duration

12 months