Prior authorization required for listed DPP-4 products

Prior authorization is required for all listed DPP-4 inhibitor products. If the request is for a combination DPP-4/SGLT2 product (e.g., Glyxambi, Trijardy XR, Qtern, Steglujan), refer to the SGLT2 policy CP.PMN.14.

Prior authorization and product redirection (generic preference)

Prior authorization criteria have been revised to add newly approved branded agents and to prefer/redirection to generic sitagliptin and sitagliptin/metformin when available; certain brand products are redirected to generics per revisions.

• Added new branded products (e.g., Zituvio, Zituvimet, Brynovin) to the criteria over multiple updates.
• Per June SDC updates, generic sitagliptin and generic sitagliptin/metformin were added as preferred products and brand Januvia/Zituvio or Janumet/Janumet XR/Zituvimet/Zituvimet XR are redirected to generics.

Metformin trial or concurrent therapy requirement

Initial approval generally requires failure of ≥ 3 consecutive months of metformin unless contraindicated; alternatively, antidiabetic‑naïve members may be approved when the requested agent will be used concurrently with metformin if baseline HbA1c ≥ 8.5% (drawn within the past 3 months).

• Failure of ≥ 3 consecutive months of metformin (unless contraindicated or clinically significant adverse effects).
• For antidiabetic medication‑naïve members: concurrent use with metformin approvable if HbA1c ≥ 8.5%.

Therapy sequencing: metformin-first strategy and escalation

Per ADA and AACE/ACE guidance referenced in the policy, metformin is recommended first-line for type 2 diabetes; escalate to dual therapy (metformin plus another agent) or additional combination therapy based on HbA1c response, typically reassessing approximately every 3 months.

• Metformin monotherapy is recommended for most patients; consider dual therapy if baseline HbA1c is ≥1.5% above target.
• Therapy sequencing follows monotherapy → dual → triple → insulin as clinically indicated with ~3-month response timelines.

Required documentation: clinical support for criteria

Submit supporting documentation with the prior authorization request, such as office chart notes, laboratory results, or other clinical information demonstrating the member meets all approval criteria.

• Provide documentation that confirms diagnosis, prior therapies tried, and clinical rationale for requested agent.

Required documentation: prior metformin use, baseline HbA1c, dosing

Document prior metformin use (duration and reason for discontinuation if applicable) and provide a baseline HbA1c (drawn within the past 3 months); dosing and formulation of the requested product must be specified per the listed dosing regimens.

• Evidence of ≥3 months of metformin use when applicable, or documentation of contraindication/adverse effect.
• Baseline HbA1c value drawn within past 3 months to support antidiabetic‑naïve approvals.
• Specify requested product dose and formulation consistent with Dosage and Administration.

Unauthorized indications require off‑label documentation

Requests for non‑FDA approved indications that are not addressed in this policy will not be authorized unless sufficient documentation is provided per the off‑label use policy (CP.PMN.53) or applicable evidence of coverage documents.

Triggers for denial: hypersensitivity, contraindications, duplicate therapy

Requests may be denied if the member has a history of serious hypersensitivity to the requested drug, has contraindicated renal impairment for metformin‑containing or certain combination products, or if the requested product is being used concurrently with a GLP‑1 receptor agonist.

• History of serious hypersensitivity reaction to the requested drug product.
• Severe renal impairment for metformin‑containing products or moderate to severe impairment for Qtern/Qternmet XR.
• Concurrent use with a GLP‑1 receptor agonist (duplicate therapy) is not permitted.