Ertugliflozin and Metformin (Segluromet™)

SELF ADMINISTRATION

Indications for Prior Authorization:

  • Indicated as an adjunct to diet and exercise to improve glycemic control in adults with Type 2 Diabetes Mellitus who are not adequately controlled on a regimen containing Ertugliflozin or Metformin, or in patients who are already treated with both Ertugliflozin and Metformin
  • Limitation of use: Not for the treatment of Type 1 Diabetes Mellitus or Diabetic Ketoacidosis

Patients must meet the following criteria for the indication(s) above:

  • Patient has a diagnosis of Type 2 Diabetes Mellitus, AND
  • Patient has tried and failed a preferred SGLT2 inhibitor (e.g. Invokana® or Jardiance®) and Metformin as separate or combined products, OR
  • Chart note documentation is provided documenting a medically appropriate reason why combination therapy is necessary, AND
  • Patient does not have a contraindication to therapy: 
    • Severe renal impairment, end-stage renal disease (ESRD), or patients on dialysis
    • Metabolic acidosis, including Diabetic Ketoacidosis

Dosing:

  • Doses are individualized based on the patient's current regimen
  • Segluromet™ is taken twice daily
  • Maximum recommended dose: 7.5mg ertugliflozin-1,000mg metformin twice daily

Approval:

  • 1 year

Last review date: June 11, 2019