Trijardy XR — Medical Mutual

type 2 diabetes mellitus

Preferred products

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, Glucophage XR, Glumetza, Fortamet, Riomet, metformin oral solution, Riomet ER, metformin extended-release (generics to Fortamet and Glumetza), metformin/glyburide, metformin/glipizide, Actoplus Met, pioglitazone/metformin, Actoplus Met XR, Janumet, Janumet XR, repaglinide/metformin, Kombiglyze XR, Jentadueto, Jentadueto XR, Kazano, aloglitpin/metformin, Synjardy, Synjardy XR, Xigduo XR, Invokamet, Invokamet XR, Segluromet; OR
Patient has tried a DPP-4 inhibitor (e.g., Januvia, Nesina, alogliptin, Onglyza, Tradjenta), a DPP-4 inhibitor-containing product (e.g., Oseni, alogliptin/pioglitazone), or an SGLT-2 inhibitor (e.g., Farxiga, Invokana, Jardiance, Steglatro), other than Glyxambi, Qtern, Steglujan, or Trijardy XR; OR
Patient has a contraindication to metformin according to the prescriber (examples include acute or chronic metabolic acidosis, including diabetic ketoacidosis)

Patient is continuing therapy with the requested non-preferred agent after being stable for at least 90 days AND
Patient has at least 130 days of prescription claims history supporting that the requested non-preferred agent has been received for 90 days within a 130-day look-back period AND there is no generic equivalent available for the requested nonpreferred product (AA- or AB-rated); OR
When 130 days of prescription claims history are unavailable, the prescriber verifies that the patient has been receiving the requested non-preferred agent for 90 days via paid claims (not samples or coupons) AND there is no generic equivalent available
Exception criteria: Approve if patient has an atypical diagnosis and/or unique patient characteristics preventing use of all preferred agents; OR patient has a contraindication to all preferred agents

12 months