Xigduo XR — Medica
type 2 diabetes mellitus
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 one metformin-containing product (Fortamet ER, Glucophage, Glucophage XR, Glumetza ER, Riomet, metformin oral solution, Riomet ER, metformin extended-release generics to Fortamet ER or Glumetza ER, glyburide/metformin, glipizide/metformin, Actoplus Met, pioglitazone/metformin, Actoplus Met XR, repaglinide/metformin, Kazano, alogliptin/metformin, Jentadueto, Jentadueto XR, Kombiglyze XR, saxagliptin/metformin extended-release, Janumet, Janumet XR, sitagliptin/metformin authorized generic to Zituvimet, Zituvimet, or Zituvimet XR); OR
- Patient has tried one Step 2 Product; OR
- Patient has tried one Step 3 Product; OR
- Patient will be initiating dual therapy with metformin AND Farxiga or Jardiance; OR
- Patient has a contraindication to metformin, according to the prescriber (examples include acute or chronic metabolic acidosis, including diabetic ketoacidosis); OR
- Patient has heart failure; OR
- Patient has chronic kidney disease; OR
- Patient has atherosclerotic cardiovascular disease or at least two risk factors for cardiovascular disease; OR
- Patient has type 2 diabetes AND peripheral arterial disease
Approval duration
1 year