Synjardy XR — Medical Mutual
Atherosclerotic cardiovascular disease
Preferred products
- generic metformin
- generic metformin-extended release (generic to Glucophage XR only)
Initial criteria
- For Step 2 Products: If the patient has tried one Step 1 Product, approve a Step 2 Product
- For Step 2 Products: A trial of specified metformin-containing products also satisfies requirement
- For Step 2 Products: If the patient has tried one Step 2 Product, approve the requested Step 2 Product
- For Step 2 Products: If the patient has tried one Step 3 Product, approve the requested Step 2 Product
- For Step 2 Products: If the patient will be initiating dual therapy with metformin AND Farxiga or Jardiance, approve Farxiga or Jardiance
- For Step 2 Products: If the patient has a contraindication to metformin, approve Farxiga or Jardiance
- For Step 2 Products: If the patient has heart failure, approve Farxiga or Jardiance
- For Step 2 Products: If the patient has chronic kidney disease, approve Farxiga or Jardiance
- For Step 2 Products: If the patient has atherosclerotic cardiovascular disease OR has at least two risk factors for cardiovascular disease, approve Farxiga or Jardiance
- For Step 3 Products: If the patient has tried one Step 2 Product, approve a Step 3 Product (a trial of a Step 1 Product is required prior to Step 2 Product unless exceptions apply)
Reauthorization criteria
- Initial Approval: 2 years
- Extended Approval: 2 years
- Approval for continuation of therapy provided for 1 year unless otherwise noted
Approval duration
2 years initial, 2 years reauth, 1 year continuation exception