FORTAMET ER (metformin)

SELF-ADMINISTRATION

Indication for Prior Authorization: 

Indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus

Coverage Criteria:

1. For diagnosis of type 2 diabetes mellitus

  • Dose does not exceed 2 g per day, AND
  • Documented diagnosis of type 2 diabetes mellitus, AND
  • Trial and failure of metformin extended-release (Glucophage XR) with documentation supporting for treatment failure that would not be expected with metformin extended-release OSM (note: treatment failure due to ineffectiveness of metformin extended-release is not considered towards metformin extended-release OSM formulation prior authorization approval)
Reauthorization Criteria:

For diagnosis of type 2 diabetes mellitus

  • Dose does not exceed 2 g per day, AND
  • Documentation of a positive clinical response to therapy
Coverage Duration:
  • Initial: 1 year
  • Reauthorization: 1 year
Dosing:
  • Maximum: 2 g per day
Authorization is not covered for the following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Policy Updates:
  • 10/19/2021 – Updated policy to remove IR formulations
  • 2/16/21- Annual review.  Developed criteria for high-cost Metformin ER (generic to Fortamet) and format updated.  
References:
  • Fortamet Prescribing Information. Actavis Laboratories FL, Inc. Fort Lauderdale, FL. November 2018
  • Glumetza Prescribing Information. Salix Pharmaceuticals. Bridgewater, NJ.  November 2018

 

 

Last review date: October 19, 2021

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