SGLT2 Inhibitors
Drug - SGLT2 Inhibitors
July 2018
Therapeutic Area - Hypoglycemics
Single-entity Products
Preferred |
Nonpreferred |
Invokana
Farxiga
Jardiance
|
Steglatro |
Fixed Dose Combination Products
Preferred |
Nonpreferred |
None |
Invokamet
Invokamet XR
Xigduo XR
Synjardy
Synjardy XR
Segluromet
Steglujan
|
Approval criteria for nonpreferred single entity products
- Patient is 18 years of age or older AND
- Patient must have a diagnosis of type 2 diabetes mellitus AND
- Patient has not achieved adequate glycemic control on at least three of the following used separately or simultaneously:
- metformin (alone or in combination with a sulfonylurea or a thiazolidinedione);
- a sulfonylurea (alone or in combination with metformin);
- an oral DPP IV inhibitor (e.g., Januvia, Onglyza)
- a preferred GLP-1 receptor agonist AND
- Patient has had an adequate adherent trial and failure of (or contraindication to) at least 2 preferred SGLT2 inhibitors
AND
Patient must not have any one of the following conditions:
- Estimated glomerular filtration rate (eGFR) < 30mL/min/1.73m2
- End-stage renal disease (ESRD)
- Be on dialysis
Approval criteria for nonpreferred fixed dose combination products
- Patient must meet ALL criteria for nonpreferred single entity products AND
- Prescriber provides a compelling clinical reason why a fixed dose combination will provide superior efficacy than each component taken separately AND
- If an extended release (XR) formulation is requested, prescriber provides a compelling clinical reason why the XR formulation will provide better clinical results than non-XR formulation
Quantity limits
- Single entity products and extended release formulation of fixed dose combination products: 34 tablets per 34 days
- Fixed dose combination products: 68 tablets per 34 days
Questions
MHCP Provider Call Center 651-431-2700 or 800-366-5411