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SGLT2 Inhibitors

DrugSGLT2 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 (eg, 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

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