alogliptin/metformin — Cigna

Preferred products

• generic metformin
• generic metformin extended-release (generic to Glucophage XR only)

Initial criteria

• If the patient has tried one Step 1 Product, approve a Step 2 Product.
• A trial of one of the following metformin-containing products also satisfies the requirement: Fortamet ER (obsolete), Glucophage (obsolete), Glucophage XR (obsolete), Glumetza ER, Riomet, metformin oral solution, Riomet ER (obsolete), metformin extended-release (generics to Fortamet ER and Glumetza ER), glyburide/metformin, glipizide/metformin, Actoplus Met, pioglitazone/metformin, Actoplus Met XR (obsolete), repaglinide/metformin (obsolete), Invokamet, Invokamet XR, Synjardy, Synjardy XR, Xigduo XR, dapagliflozin/metformin extended-release, Segluromet.
• If the patient has tried one Step 2 Product, approve the requested Step 2 Product.
• If the patient is initiating dual (combination) therapy with a single-entity DPP-4 inhibitor (Januvia, Onglyza, saxagliptin, Tradjenta, Nesina, alogliptin, Zituvio, or sitagliptin [authorized generic to Zituvio]) AND metformin, approve a single-entity DPP-4 inhibitor.
• If the patient has a contraindication to metformin, according to the prescriber, approve a single-entity DPP-4 inhibitor. Examples of contraindications include acute or chronic metabolic acidosis, including diabetic ketoacidosis.

Approval duration

1 year