CurrentCignaPolicy N/A

Diabetes - Metformin Extended-Release Drug Quantity Management Policy - Per Rx

Defines per‑prescription quantity limits and medically necessary exceptions for generic metformin extended‑release products (including Glumetza generic) for Cigna‑administered health benefit plans.

Policy Summary

PayerCigna

PolicyMetformin Extended-Release Drug Quantity Management

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionAll prior authorizations are approved for 1 year; if quantity limits are exceeded at point of service, determine coverage per the specified medical necessity criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30Retail max (500 mg Fortamet generic)

90Home delivery max (500 mg Fortamet generic)

60Retail max (1000 mg Fortamet/Glumetza)

120Retail max (500 mg Glucophage XR/Glumetza)

1 yrAuthorization duration

Coverage Criteria

Policy Summary

PayerCigna

PolicyMetformin Extended-Release Drug Quantity Management

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionAll prior authorizations are approved for 1 year; if quantity limits are exceeded at point of service, determine coverage per the specified medical necessity criteria.

SourceLink

On This Page

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Metformin 500 mg ER (generic to Fortamet) — exception

Covered as medically necessary when ALL of the following are met for metformin 500 mg ER (generic to Fortamet) at 1,500 mg/day:

Quantity exception for 1,500 mg/day: Patient is taking 1,500 mg per day; approve 90 tablets per dispensing at retail or 270 tablets per dispensing at home delivery (30‑day retail / 90‑day home delivery supply).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, switch to metformin immediate‑release tablets as noted in product guidance.

Products without quantity exceptions

No quantity limit overrides recommended for the following products:

No overrides: Metformin 1,000 mg ER (generic to Fortamet); Metformin 500 mg and 750 mg ER (generic to former Glucophage XR); Metformin 500 mg and 1,000 mg ER (Glumetza, generic).

Any requests exceeding published quantity limits for these products are not described as having exceptions in this policy and are considered not medically necessary unless specifically listed.

Any exception to the drug quantity limits in this policy that is not explicitly described is considered not medically necessary. The policy text states that exceptions listed as covered are only those specifically detailed; all other exception requests are not covered.

Quantities that exceed the published drug quantity limits and do not meet the policy's specified exception criteria are considered not medically necessary. If the Drug Quantity Management rule is not met at point of service, coverage will be determined according to the policy criteria and out‑of‑limits quantities without an approved exception are not covered.

Per‑Product Quantity Limits

Quantity limit — retail

Drugmetformin ER (generic to Fortamet) 500 mg

Quantity (retail)30 tablets per Rx

Unittablets

Quantity limit — home delivery

Drugmetformin ER (generic to Fortamet) 500 mg

Quantity (home delivery)90 tablets per Rx

Unittablets

Quantity limit — retail

Drugmetformin ER (generic to Fortamet) 1,000 mg

Quantity (retail)60 tablets per Rx

Unittablets

Quantity limit — home delivery

Drugmetformin ER (generic to Fortamet) 1,000 mg

Quantity (home delivery)180 tablets per Rx

Unittablets

Quantity limit — retail

Drugmetformin HCl ER (generic to Glucophage XR) 500 mg

Quantity (retail)120 tablets per Rx

Unittablets

Quantity limit — home delivery

Drugmetformin HCl ER (generic to Glucophage XR) 500 mg

Quantity (home delivery)360 tablets per Rx

Unittablets

Quantity limit — retail

Drugmetformin HCl ER (generic to Glucophage XR) 750 mg

Quantity (retail)60 tablets per Rx

Unittablets

Quantity limit — home delivery

Drugmetformin HCl ER (generic to Glucophage XR) 750 mg

Quantity (home delivery)180 tablets per Rx

Unittablets

Quantity limit — retail

DrugGlumetza (metformin ER) 500 mg

Quantity (retail)120 tablets per Rx

Unittablets

Quantity limit — home delivery

DrugGlumetza (metformin ER) 500 mg

Quantity (home delivery)360 tablets per Rx

Unittablets

Quantity limit — retail

DrugGlumetza (metformin ER) 1,000 mg

Quantity (retail)60 tablets per Rx

Unittablets

Quantity limit — home delivery

DrugGlumetza (metformin ER) 1,000 mg

Quantity (home delivery)180 tablets per Rx

Unittablets

Provider Actions & Authorization

Documentation Required

Plan & documentation requirements

Coverage per the member's benefit plan applies. Prior authorization requirements, covered benefit determination, and applicable billing rules vary by Cigna customer and the specific benefit plan in effect on the date of service. Verify the member's plan for coverage of extended‑release metformin and for any applicable exclusions or limits before submitting a request.

Confirm applicable benefit plan document (Evidence of Coverage/Group Service Agreement) before approval.
Claims must be billed with the most appropriate diagnosis and procedure/drug codes as of the date of service.
If a Drug Quantity Management rule is not met at the point of sale, coverage will be evaluated against the policy criteria.

Documentation Required

Required clinical documentation

Clinical documentation must support the request and demonstrate medical necessity per the member's benefit plan and the policy criteria. Include prior therapy, dosing history, rationale for extended‑release formulation, and any relevant laboratory or clinician notes.

Supply previous antidiabetic therapy details and response/tolerability.
Document current HbA1c and other relevant labs when available.
If requesting a quantity or duration beyond typical limits, provide supporting rationale and clinical notes.

Step Therapy

Therapy escalation guidance

Start extended‑release metformin at 500 mg once daily with the evening meal and titrate in 500 mg weekly increments as tolerated. Maximum recommended once‑daily dose is 2,000 mg; if additional glycemic control is needed consider 1,000 mg twice daily. If higher total daily doses are required beyond these limits, switch to immediate‑release metformin per product labeling.

Initial dosing: 500 mg QD with evening meal; increase by 500 mg weekly as tolerated.
Maximum recommended ER dosing: 2,000 mg QD (or consider 1,000 mg BID if needed).
For total daily doses above labeled ER limits (per Glucophage XR guidance), convert to immediate‑release metformin (IM) to achieve higher total daily doses up to product‑specified limits.

Prior Authorization

Authorization duration and process

All prior authorizations granted under this Drug Quantity Management program are valid for 1 year from the approval date.

Approvals are effective for 12 months.
If quantity management criteria are not met at point of sale, adjudication will follow the policy criteria and submitted documentation.

Background

Extended‑release metformin products are indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Recommended dosing begins at 500 mg once daily with the evening meal and may be titrated by 500 mg weekly up to typical maximums; product labeling notes switching to immediate‑release metformin if higher total daily doses are required. For the specific quantity exception described in this policy, metformin 500 mg ER (generic to Fortamet) is eligible for an exception when the patient is taking 1,500 mg per day, in which case the policy approves 90 tablets per dispensing at retail (30‑day supply) or 270 tablets per dispensing at home delivery (90‑day supply).

OpenPayer

Diabetes - Metformin Extended-Release Drug Quantity Management Policy - Per Rx

Coverage Criteria

Per‑Product Quantity Limits

Provider Actions & Authorization

Definitions

Background