CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Coverage criteria for Trijardy XR (fixed‑dose combination for type 2 diabetes)

Defines medical necessity criteria, quantity limits, and coverage duration for Trijardy XR for members of Neighborhood Health Plan of Rhode Island; applies to prescribers requesting pharmacy benefit authorization.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCoverage criteria for Trijardy XR (fixed‑dose combination for type 2 diabetes)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization showing patient is ≥18 and has inadequate glucose control after adequate/maximized metformin and a formulary SGLT2 inhibitor.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18minimum patient age for approval

12 moauthorization / coverage duration

1–2/dayquantity limits

10/2021–4/2024review history

Coverage and Medical Necessity Criteria

Initial approval

Covered when ALL of the following are met:

Age requirement: Patient is 18 years or older>=18 years

Prior therapy: Patient has not achieved adequate glucose control using an adequate/maximized dose of metformin, or a formulary SGLT2 inhibitor or combination product (e.g., dapagliflozin, empagliflozin [Jardiance], ertugliflozin [Steglatro])

Authorization of 12 months may be granted when met

Coverage duration: Authorization granted for 12 months12 months

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCoverage criteria for Trijardy XR (fixed‑dose combination for type 2 diabetes)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization showing patient is ≥18 and has inadequate glucose control after adequate/maximized metformin and a formulary SGLT2 inhibitor.

SourceLink

On This Page

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Use of Trijardy XR is limited to patients who meet the authorization criteria. The policy requires that the patient be at least 18 years of age. Prior therapeutic optimization is required: the patient must have not achieved adequate glucose control on an adequate/maximized dose of metformin or a formulary SGLT2 inhibitor or combination product (examples listed in the policy include dapagliflozin, empagliflozin [Jardiance], and ertugliflozin [Steglatro]). Requests for patients under 18 years or before trials of metformin and an SGLT2 inhibitor have been attempted are not consistent with the approval criteria.

Authorization, Step Therapy, and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Approval may be granted for up to 12 months when all authorization criteria are met.

Authorization duration: 12 months

Step Therapy

Step Therapy Requirement

A step therapy requirement applies. Member must have tried and not achieved adequate glucose control with metformin and a formulary SGLT2 inhibitor (or an adequate/maximized dose of these agents) prior to approval.

Required prior therapies: metformin; formulary SGLT2 inhibitor (e.g., dapagliflozin, empagliflozin [Jardiance], ertugliflozin [Steglatro])

Documentation Required

Required Documentation

Documentation must be submitted to support that the member is ≥18 years old and has failed to achieve adequate glucose control despite an adequate/maximized dose of metformin or a formulary SGLT2 inhibitor. Include clinical notes, medication history (dosing and duration), and recent glycemic control data (e.g., A1c values) demonstrating inadequate control.

Proof of age: date of birth in chart
Medication history: names, doses, dates of metformin and SGLT2 inhibitor trials
Clinical data: recent A1c or glucose measurements showing inadequate control

Denial Risk

Denial Triggers

Requests will be denied if the member is under 18 years of age or there is no documentation of an adequate trial of metformin and a formulary SGLT2 inhibitor (including dose and duration), or if clinical data do not demonstrate inadequate glucose control. Requests lacking necessary supporting documentation (medication history or glycemic data) will also be denied.

Denial triggers: member <18 years; no documented adequate trial of metformin and formulary SGLT2 inhibitor; missing medication history or glycemic data

Definitions and Formulary References

inv-09: Adequate/maximized dose — definition entry

DefinitionAdequate/maximized dose: patient has not achieved adequate glucose control despite being treated with an adequate or maximized dose of metformin (or other referenced agent).

Context in criteriaUsed as a required prior-therapy condition — authorization may be granted only if adequate glucose control was not achieved on an adequate/maximized dose of metformin or a formulary SGLT2 inhibitor/combo product.

Implication for documentationProvider must document that metformin was used at an adequate or maximized dose and that glucose control remained inadequate before Trijardy XR approval.

inv-10: Formulary SGLT2 inhibitor — examples listed

Examples listed in policyDapagliflozin; Empagliflozin (Jardiance); Ertugliflozin (Steglatro)

ClassFormulary Sodium-Glucose Cotransporter 2 (SGLT2) inhibitors referenced in the criteria.

Role in step therapyA trial of a formulary SGLT2 inhibitor (one of the listed agents) is required and must have failed to achieve adequate glucose control before approval.

OpenPayer

Coverage criteria for Trijardy XR (fixed‑dose combination for type 2 diabetes)

Coverage and Medical Necessity Criteria

Authorization, Step Therapy, and Documentation Requirements

Clinical Background

Definitions and Formulary References