CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

DPP-4 Inhibitors (Alogliptin and combinations) Coverage Criteria

Coverage policy for alogliptin and alogliptin combination products (alogliptin-metformin, alogliptin-pioglitazone) for glycemic control in members, including required prior medical information and coverage duration.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDPP-4 Inhibitors (Alogliptin and combinations) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2012

Next Review DateN/A

Key ActionObtain prior authorization documenting metformin at an adequate/maximized dose (2 g/day) and duration failed to achieve adequate glucose control.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3drugs named in policy

12 mostandard coverage duration

2 g/daymetformin maximized dose

2012-2025review history entries

Coverage Criteria

Initial Therapy

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDPP-4 Inhibitors (Alogliptin and combinations) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2012

Next Review DateN/A

Key ActionObtain prior authorization documenting metformin at an adequate/maximized dose (2 g/day) and duration failed to achieve adequate glucose control.

SourceLink

On This Page

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Covered when ALL of the following are met:

Initial coverage criteria for alogliptin: Patient has not achieved adequate glucose control on an adequate/maximized dose and appropriate duration of metformin (2 g/day); AND alogliptin will not be used in conjunction with a GLP-1 agonist.metformin 2 g/day

Prior authorization required; coverage duration: 12 months.

Coverage for alogliptin and its combination products does not extend to uses considered investigational. Investigational use is defined as use at a dose or for a condition that is not recognized as a medically accepted indication by standard compendia (AHFS‑DI, Micromedex DrugDex, Clinical Pharmacology, Lexi‑Drugs) or supported by peer‑reviewed medical literature. Therapies classified as investigational may be denied.

Key Coding & Dosage

Metformin maximized dose

Metformin maximized dose2 grams/day

Context for requirementPrior authorization requires documentation that metformin at an adequate/maximized dose and duration failed to achieve adequate glucose control

Where appliedInitial therapy and prior authorization criteria for alogliptin and combination products

Provider Actions & Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Documentation must show the patient has not achieved adequate glucose control despite metformin at an adequate/maximized dose (2 g/day) given for an appropriate duration. Alogliptin (including combination products) must not be used concurrently with a GLP‑1 receptor agonist.

Coverage duration: 12 months
Do not combine Alogliptin with a GLP‑1 receptor agonist
Investigational uses (unapproved dose/indication) are not covered

Documentation Required

Provide clinical records showing metformin dose and duration, and recent glycemic control measures (e.g., A1c) demonstrating inadequate control despite therapy. Include rationale if prescribing an Alogliptin combination product.

Include metformin dose (up to 2 g/day) and treatment duration
Attach recent A1c or other glycemic control data
Specify if using Alogliptin combination product and indication

Denial Risk

Investigational Use Not Covered

Neighborhood does not provide coverage for Alogliptin when used for investigational purposes — defined as use at a dose or for a condition not recognized as a medically accepted indication in standard reference compendia (AHFS, DrugDex, Clinical Pharmacology, Lexi‑Drugs) or supported by peer‑reviewed literature.

Not covered: investigational doses or indications lacking compendia support

Initial Therapy

Initial therapy: Patient inadequate response to metformin at an adequate/maximized dose (2 g/day) and not using a GLP-1 agent concurrently.metformin 2 g/day

Prior authorization requires documentation of metformin trial and that alogliptin will not be used with a GLP-1 agonist.

Continuation / Duration Criteria

Continuation/Duration

Continuation: Coverage duration is 12 months for approved therapy.12 months

Background

Alogliptin and its fixed‑dose combinations with metformin or pioglitazone are members of the Dipeptidyl Peptidase‑4 (DPP‑4) inhibitor class — oral antihyperglycemic agents used to improve glycemic control in patients with type 2 diabetes. This policy frames coverage for these agents when a patient has not achieved adequate glucose control on an adequate/maximized dose and appropriate duration of metformin (2 grams/day), and it prohibits concurrent use with a GLP‑1 receptor agonist. Standard coverage duration for approved therapy is 12 months.

Definitions

Investigational — definition

DefinitionInvestigational use: use at a dose or for a condition other than those recognized as medically accepted indications per standard compendia (AHFS-DI, Micromedex DrugDex, Clinical Pharmacology, Lexi-Drugs) or supported by peer-reviewed literature.

Coverage stanceNeighborhood does not provide coverage for therapies used for investigational purposes.

Examples of compendia referencedAmerican Hospital Formulary Service (AHFS-DI); Thomson Micromedex DrugDex; Clinical Pharmacology; Wolters Kluwer Lexi-Drugs; peer-reviewed published medical literature