Trijardy XR — Medica

Preferred products

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

Initial criteria

• Patient has tried one Step 1 Product (generic metformin or generic metformin extended-release [generic to Glucophage XR only])
• OR Patient has tried one of the following metformin-containing products: Glucophage (obsolete), Glucophage XR (obsolete), Glumetza ER, Fortamet ER (obsolete), 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), Janumet, Janumet XR, Zituvimet, sitagliptin/metformin (authorized generic to Zituvimet), Zituvimet XR, repaglinide/metformin (obsolete), Kombiglyze XR, saxagliptin/metformin extended-release, Jentadueto, Jentadueto XR, Kazano, alogliptin/metformin, Synjardy, Synjardy XR, Xigduo XR, dapagliflozin/metformin extended-release, Invokamet, Invokamet XR, Segluromet
• OR Patient has tried a DPP-4 inhibitor, a DPP-4 inhibitor-containing product, OR an SGLT-2 inhibitor (other than Glyxambi, Qtern, Steglujan, or Trijardy XR)
• Examples of DPP-4 inhibitors include Januvia, Nesina, alogliptin, Onglyza, saxagliptin, Tradjenta, Zituvio, sitagliptin (authorized generic to Zituvio); examples of DPP-4 inhibitor-containing products include Oseni and alogliptin/pioglitazone; examples of SGLT-2 inhibitors include Brenzavvy, bexagliflozin, Farxiga, dapagliflozin, Invokana, Jardiance, Steglatro
• OR Patient has a contraindication to metformin according to the prescriber (e.g., acute or chronic metabolic acidosis, including diabetic ketoacidosis)

Approval duration

1 year