Diabetes - Metformin Extended-Release Drug Quantity Management Policy - Per Rx
Defines per-prescription quantity limits and coverage criteria for extended-release metformin products (generic equivalents to Fortamet and Glucophage XR, and Glumetza) for Cigna-administered health benefit plans.
No material clinical or coverage changes in this revision.
Coverage Criteria and Drug Quantity Management
Drug Quantity Limits and Product-specific Exceptions
Products are covered as medically necessary when the Drug Quantity Management limits and the criteria below are met. Any other exception is considered not medically necessary.
Per-product quantity limits and rules
- Metformin 500 mg (generic to Fortamet): Retail maximum 30 tablets per Rx; Home Delivery maximum 90 tablets per Rx. Exception: if the patient is taking 1,500 mg per day, approve 90 tablets per dispensing at retail or 270 tablets per dispensing at home delivery (90 tablets = 30-day supply at 1,500 mg/day; 270 tablets = 90-day supply at 1,500 mg/day). If the patient is taking 1,000 mg or 2,000 mg daily, refer to the 1,000 mg tablet. If a higher total daily dose is required beyond labeled extended‑release dosing, metformin immediate‑release tablets should be used.30/90 (retail/home); exception 90/270 for 1,500 mg/day
- Metformin 1,000 mg (generic to Fortamet): Retail maximum 60 tablets per Rx; Home Delivery maximum 180 tablets per Rx. No overrides recommended.
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