SGLT2 inhibitors initial and continuation request form/criteria
Form and clinical criteria for initial and continuation prior authorization requests for SGLT2 inhibitors (preferred and non-preferred products) including required clinical questions about diagnoses, prior metformin trial/contraindication, CV/kidney disease status, and extra requirements for non-preferred products (trial of two preferred agents). Also captures provider/prescriber information, drug quantity/duration, and mandatory prescriber signature.
No material clinical/coverage changes in this update.
Coverage Summary
Coverage stance: covered_with_criteria for SGLT2 inhibitors when initial or continuation criteria on the form are met. The form requires that ALL initial request criteria be satisfied, including diagnosis fields (e.g., heart failure and Type 2 Diabetes), documentation of a trial and failure or insufficient response to metformin (or a documented contraindication/adverse event to metformin), and presence of established ASCVD, heart failure, or chronic kidney disease (CKD) as indicated on the checklist. For non-preferred products, the form additionally requires evidence of trial and failure (or insufficient response) to at least two preferred products or a listed clinical reason why preferred products cannot be used. Continuation coverage is granted only when all continuation criteria are met, such as documentation that the beneficiary has improved while on the medication, that individual clinical goals are being met, and that the beneficiary is making adequate progress toward treatment goals.