Kombiglyze XR — CareFirst (Caremark)

Preferred products

• metformin

Initial criteria

• Diagnosis of type 2 diabetes mellitus
• The patient has NOT been receiving a stable maintenance dose of the requested drug for at least 3 months AND ONE of the following:
• The patient has experienced an inadequate treatment response, intolerance, or contraindication to metformin
• OR The patient requires combination therapy AND has an A1C ≥ 7.5 percent

Reauthorization criteria

• Diagnosis of type 2 diabetes mellitus
• The patient has been receiving a stable maintenance dose of the requested drug for at least 3 months
• The patient has demonstrated a reduction in A1C since starting this therapy

Approval duration

36 months