metformin extended-release tablets (Glumetza™)

 FDA Approved Indication(s):

  • Metformin ER (Glumetza) is indicated for the treatment of type 2 diabetes as monotherapy (in adjunct to diet and exercise) and in combination with insulin or a sulfonylurea. It is indicated in patients ≥ 18 years of age

All of the following must be met as a condition(s) for coverage:

  • Medication is being used for an FDA approved indication

  • Documentation that generic metformin ER (Glucophage equivalent) as well as metformin ER (osmotic) (Fortamet equivalent) were ineffective or not tolerated as validated from prescription claims history and medical record documentation. Medical record documentation must include the trial and intolerance of the metformin ER (Glucophage equivalent) and metformin ER (osmotic) products and must be included with the prior authorization request

Approval:

  • Authorization for 1 year if approved
  • Renewal must include medical record documentation supporting the need for continued therapy (e.g., solution)

 

Last review date: July 25, 2016

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