CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Riomet (metformin solution) prior authorization request form / coverage criteria

This document is a prior authorization request form used by providers to request coverage of Riomet (metformin solution) from the payer's pharmacy benefit manager; it affects prescribing clinicians and pharmacy prior authorization reviewers.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyRiomet (metformin solution) prior authorization request form / coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the Riomet prior authorization form with clinical documentation, a 90-day trial history of formulary alternatives (or contraindication evidence), dosing justification, and prescriber signature via fax (844-403-1029) or the CoverMyMeds/OptumRx portal.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 pagesform length

844-403-1029fax for submissions

go.covermymeds.com/OptumRxonline portal

855-811-2218PA support

Coverage Criteria

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Initial coverage criteria

Coverage will be considered when ALL of the following are provided:

Form completion and prescriber attestation: Completed PA form including prescriber signature and date, provider and member information, and medication directions

Required form elements located on pages 1-2

Diagnosis: Selected diagnosis (e.g., Type 2 diabetes mellitus) with ICD-10 code or other documented diagnosis

Form provides checkbox for Type 2 diabetes mellitus and space for other diagnoses (ICD-10 code)

Step therapy documentation: Documentation of a 90-day trial and failure or intolerance to a majority of preferred formulary alternatives (or documentation of contraindication/adverse reaction) including medications tried, dates, and reasons for failure90-day trial

Form requests submission of medications tried, dates of trials, and reasons for failure; examples given: generic metformin and generic metformin extended-release

Alternatives contraindicated or not available: If patient has documented contraindication to listed formulary alternatives OR has a clinical condition for which no listed formulary agent exists, submit documentation

Form includes separate checkboxes and requests documentation for contraindication, adverse reaction, or lack of listed agent

Dosing within guidelines: Prescribed dose must be within manufacturer's published dosing guidelines or accepted compendia/current literature

Form asks yes/no for dosing conformity (e.g., package insert, AHFS, Micromedex)

No explicit exclusions are listed on the Riomet prior authorization request form. The form focuses on required clinical information (diagnosis, prior trials, contraindications, adverse reactions, and dosing) rather than listing any specific conditions or member populations that are categorically excluded from consideration.

Requests for Riomet prior authorization may be denied unless all required information is received. The form instructs providers to supply prescriber signature, clinical justification, and any additional comments or documentation; missing elements can lead to denial of the request.

Provider Actions & Submission

Prior Authorization

Prior Authorization Submission Requirement

Prior Authorization Required: A completed prior authorization request form must be submitted for Riomet (metformin solution) prior to coverage. Use the manufacturer’s prior authorization request form and fax to 844-403-1029 or follow payer-specific submission processes.

Submit prior authorization BEFORE dispensing.
Use the current prior authorization form (forms are updated frequently).
Fax: 844-403-1029

Denial Risk

Incomplete Submission Risk

Incomplete submissions may result in denial or delayed review. Requests lacking required clinical information, signatures, or supporting documentation will not be processed until complete.

Missing prescriber signature or date risks denial.
Omittted documentation of prior medication trials, contraindications, or adverse reactions will delay decision.

Documentation Required

Required Clinical Documentation

Required clinical documentation must accompany the request: diagnosis and ICD-10 code; evidence of a 90-day trial and failure or intolerance to a majority of preferred formulary alternatives (list medications tried, trial dates, and reasons for failure); documented contraindications or adverse reactions to formulary alternatives if claimed; clinical rationale when no formulary agent is appropriate; and dosing justification consistent with manufacturer labeling or accepted compendia.

Diagnosis and ICD-10 code.
Documentation of 90-day trial and failure or intolerance to majority of preferred formulary alternatives (medication names, dates, reasons).
Documentation of contraindications to formulary alternatives (medication name and contraindication).
Documentation of adverse reactions to formulary agents (medication name and reaction).
Clinical justification if no formulary agent exists for the condition.
Confirmation that prescribed dose is within manufacturer or accepted compendia dosing guidelines.

Background

Riomet (metformin solution) is an oral metformin formulation used for glycemic control in type 2 diabetes mellitus. The prior authorization form collects the confirmed diagnosis (with ICD-10 code), documentation of a 90-day trial and failure or intolerance to a majority of preferred formulary metformin alternatives (or documentation of contraindication or adverse reaction), and confirmation that dosing is within the manufacturer's or accepted compendia guidelines. The form also provides space for prescriber signature, dates, and additional clinical comments to support the medical necessity of Riomet.

Initial Therapy Criteria

Initial therapy requirements

Initial authorization requires completion of the form with clinical justification.

Diagnosis and trials: Documented diagnosis (e.g., Type 2 diabetes mellitus) and a 90-day trial and failure or intolerance to a majority of preferred formulary alternatives, or documentation of contraindication/adverse reaction90-day trial

Provider must list medications tried, dates, and reasons for failure or intolerance on the form

Dosing conformity: Dose must be within manufacturer's published dosing guidelines or accepted compendia/current literature

Form includes a yes/no question regarding dosing conformity (e.g., package insert, AHFS, Micromedex)

Continuation / Renewal Criteria

Continuation/Renewal

Continuation requires ongoing documentation as implied by prescriber comments and any additional information requested by reviewer.

Ongoing documentation: Any continuation or renewal may require updated documentation of continued clinical need, confirmation that dosing remains within manufacturer's or accepted compendia guidelines, and documentation of prior trials/contraindications as applicable

Form provides space for prescriber comments and indicates request may be denied if required information is not received; reviewer may request additional information

Step Therapy Evidence

Requirement	Details / Required documentation
Documentation of medications tried, dates, and reasons for failure or intolerance
Submit documentation of medication(s) tried, dates of trial(s), and reason(s) for treatment failure(s) for a 90-day trial and failure 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 alternatives (e.g., generic metformin, generic metformin extended‑release).