CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (Alogliptin and combinations) Coverage Criteria

Covers clinical authorization and coverage criteria for alogliptin and its combination products for glycemic control in patients who have not achieved adequate control on metformin; applies to Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDPP-4 Inhibitors (Alogliptin, combinations) — coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2012

Next Review DateN/A

Key ActionObtain prior authorization showing inadequate glucose control on maximized metformin (2 g/day) before approving alogliptin.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12coverage duration

2 g/daymetformin dose

Alogliptin(s)drugs covered

Coverage Criteria

Initial Therapy — Covered when ALL of the following are met

Covered when ALL of the following are met:

Initial Authorization Criteria: Patient has not achieved adequate glucose control using an adequate/maximized dose and appropriate duration of metformin (2 grams/day).metformin 2 g/day

Approval duration: 12 months

Initial Authorization Criteria: Alogliptin will not be used in conjunction with a GLP-1 receptor agonist.

Uses of alogliptin or its combination products that are not recognized as medically accepted indications in standard reference compendia or peer‑reviewed literature are considered investigational and are not covered. Neighborhood defines investigational use as therapy administered at a dose or for a condition other than those listed as medically accepted in sources such as AHFS‑DI, Micromedex DrugDex, Clinical Pharmacology, Lexi‑Drugs, or peer‑reviewed published medical literature.

Coding and Dosing References

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDPP-4 Inhibitors (Alogliptin, combinations) — coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2012

Next Review DateN/A

Key ActionObtain prior authorization showing inadequate glucose control on maximized metformin (2 g/day) before approving alogliptin.

SourceLink

On This Page

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Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for alogliptin products. Documentation must show the clinical rationale for use and that required prior therapies and trials have been attempted as specified below.

Applies to alogliptin, alogliptin-metformin, and alogliptin-pioglitazone
Coverage duration: 12 months

Step Therapy

Step Therapy Requirement

Step therapy requires a trial of maximized metformin therapy before authorization of alogliptin products.

Patient must have had an adequate trial of metformin at a maximized dose (up to 2 grams/day) without achieving adequate glucose control

Documentation Required

Required Clinical Information

Required clinical information must be submitted with the prior authorization request to support medical necessity.

Documentation that the patient has not achieved adequate glycemic control on metformin at an adequate/maximized dose (2 grams/day)
Statement that alogliptin will not be used concomitantly with a GLP-1 receptor agonist

Denial Risk

Investigational / Not Covered Uses

Uses considered investigational are not covered. Therapies used at doses or for indications not recognized in standard reference compendia or peer‑reviewed literature are excluded from coverage.

Reference compendia: AHFS Drug Information, Micromedex DrugDex, Clinical Pharmacology, Lexi-Drugs, or peer-reviewed published medical literature

Background

Dipeptidyl peptidase‑4 (DPP‑4) inhibitors in this policy include alogliptin and its combination products (alogliptin‑metformin, alogliptin‑pioglitazone). These oral antihyperglycemic agents are intended as adjunctive therapy for type 2 diabetes when glycemic control remains inadequate on metformin. Prior authorization and step‑therapy requirements mandate documentation that the patient has not achieved adequate glucose control on a maximized/metformin dose of 2 grams/day, and alogliptin must not be used concurrently with a GLP‑1 receptor agonist. When criteria are met, coverage is authorized for 12 months.

OpenPayer

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (Alogliptin and combinations) Coverage Criteria

Coverage Criteria

Coding and Dosing References

Provider Actions and Requirements

Background

Definitions