CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Prior Authorization Request Form for DPP-4 Inhibitors and Combinations

Form and requirements for prior authorization of alogliptin, alogliptin combinations, saxagliptin, linagliptin, and related DPP-4 inhibitor products for treatment of type 2 diabetes mellitus for Blue Cross Blue Shield - South Carolina members.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyPrior Authorization Request Form for DPP-4 Inhibitors and Combinations

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the prior authorization form with required clinical documentation to 844-403-1029.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Page 1 of 2form length

Page 2 of 2form length

844-403-1029fax

855-811-2218prior auth phone

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Primary diagnosis: Patient has a diagnosis of type 2 diabetes mellitus (adjunct to diet and exercise) or other specified diagnosis with ICD-10 code provided

Form requires selection of diagnosis and entry of ICD-10 code

Prior trials: Patient has demonstrated failure of or intolerance to a majority (two or more in a class with at least two alternatives or one in a class with only one alternative) of the preferred formulary drugs; documentation of medications tried, dates of trial(s), and reason(s) for treatment failure must be provided

Provider must submit documentation of prior medication trials (names, dates, reasons)

Contraindication or adverse reaction to formulary alternatives: Patient has a documented contraindication to listed formulary alternatives OR has had an adverse reaction to or is reasonably expected to have an adverse reaction to a majority of listed formulary agents for the requested indication; documentation of medication name(s) and contraindication/adverse reaction required

Either contraindication or adverse reaction documentation suffices

No suitable formulary agent (when applicable): If the patient has a clinical condition for which there is no listed formulary agent based on published guidelines or literature, documentation of the clinical condition must be provided

Supporting documentation required

Dosing guideline adherence: The drug is prescribed within the manufacturer's published dosing guidelines or dosing guidelines found in accepted compendia/current literature

Yes/No question on form

The form lists no explicit exclusions. If information requested on the clinical section—such as prior trials (medication names, trial dates, and reasons for failure), documented contraindications or adverse reactions, or dosing justification—is not provided, the request cannot be fully evaluated. The policy therefore treats missing required clinical documentation as a basis for denial or delay of coverage determinations.

Providers must complete the required clinical fields on the form, including diagnosis selection with ICD‑10 code and supporting documentation for prior trials or contraindications; failure to supply these items may result in denial as noted on the form.

Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for the listed DPP-4 inhibitors and combination products. The Prior Authorization Request Form must be completed and faxed to 844-403-1029.

Affected medications include: Alogliptin, Alogliptin-metformin, Alogliptin-pioglitazone, Jentadueto, Jentadueto XR, Kazano, Kombiglyze XR, Nesina, Onglyza, Oseni, Tradjenta.

Documentation Required

Failure/Intolerance to Formulary Alternatives

Provider must document failure of or intolerance to a majority of formulary alternatives (defined as two or more in a class when at least two alternatives exist, or one when only one alternative exists).

If trials completed, submit medication names, trial dates, and reasons for failure.

Documentation Required

Required Clinical Documentation

Submit documentation of prior medication trials (medication names, trial dates, and reasons for failure), documented contraindications, adverse reactions, or other supporting clinical documentation as indicated on the form.

Include medication name, strength, dosage form, directions, and dates of trials.
If contraindication or adverse reaction present, provide specific documentation and explanation.

Note

Form Completion Requirements

The Prior Authorization Request Form requires provider and member identifying information and medication details. Ensure all required fields on the form are completed.

Required provider/member fields: Member name, insurance ID#, provider name, NPI#, specialty, DOB, office phone, office fax, address.
Medication fields: medication name, strength, dosage form, directions for use.

Denial Risk

Denial risk — This request may be denied unless all required information is received. For questions about the prior authorization process, contact 855-811-2218 (Mon–Fri 8:00 a.m. – 8:00 p.m. ET; Sat 9:00 a.m. – 6:00 p.m. ET).

Fax completed form to 844-403-1029.
Ensure prescriber signature and date are included on page 2 of the form.

Background

This prior authorization form is used to request coverage for DPP-4 inhibitors and their fixed‑dose combinations as adjuncts to diet and exercise for the treatment of type 2 diabetes mellitus. The form collects the selected diagnosis (including an ICD‑10 code), documentation of prior medication trials or contraindications/adverse reactions to formulary alternatives, and confirmation that the prescribed dose is within manufacturer or accepted compendia guidelines.

Definitions

Majority failure/intolerance (step therapy requirement)

RequirementProvider must document failure of or intolerance to a majority of preferred formulary drugs (two or more in a class with at least two alternatives, or one if the class has only one alternative)

What to submitMedication(s) tried, dates of trial(s), and reason(s) for treatment failure or intolerance

Alternate pathwaysDocumented contraindication to listed formulary alternatives or documented adverse reaction to a majority of listed agents may satisfy the requirement if supported by documentation

Form locationQuestion 2 and related fields on the Clinical Information section of the prior authorization form capture these responses and documentation

Initial Therapy Criteria

Initial therapy

Initial authorization requirements

Diagnosis: Type 2 diabetes mellitus (adjunct to diet and exercise) or other specified diagnosis entered with ICD-10 code

Select diagnosis and enter ICD-10 code on form

Prior formulary failure: Failure of or intolerance to a majority (two or more in a class with at least two alternatives or one in a class with only one alternative) of preferred formulary drugs with documentation of medication(s) tried, dates, and reasons for failure

Supports step therapy requirement

Contraindication or adverse reaction: Documented contraindication to listed formulary alternatives OR adverse reaction to (or reasonable expectation of adverse reaction to) a majority of listed formulary agents; documentation required (medication names and details)

Provider may satisfy requirement with either contraindication or adverse reaction documentation

Dose conformity: Prescribed dose is within manufacturer's published dosing guidelines or dosing guidelines in accepted compendia/current literature

Yes/No field on form

Step Therapy / Prior Trials Documentation

Requirement	What to document
Document prior medication trials demonstrating failure or intolerance to a majority of preferred formulary drugs (two or more in a class with at least two alternatives, or one where only one alternative exists)
Provide medication name(s), dates of trial(s), and reason(s) for treatment failure or intolerance (as requested on the form)