Limitations of Use: Glumetza is not used for the treatment of type 1 diabetes or ketoacidosis (1).
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1 Federal Employee Program 1310 G Street, N.W. Washington, D.C Fax Subject: Glumetza Page: 1 of 5 Last Review Date: March 18, 2016 Glumetza Description Glumetza (extended-release metformin) Background Glumetza (extended-release metformin) is an oral antidiabetic medication used to improve glycemic control in adults with type 2 diabetes mellitus. Controlling high blood sugar helps prevent kidney damage, blindness, nerve problems, loss of limbs, and sexual function problems. Proper control of diabetes may also lessen your risk of a heart attack or stroke. Metformin works by helping to restore your body's proper response to the insulin you naturally produce. It also decreases the amount of sugar that your liver makes and that your stomach/intestines absorb. Glumetza is administered once daily with the evening meal. Glumetza is not a substitute for diet and exercise (1). Regulatory status FDA Approved Indications: Glumetza is a biguanide indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes (1). Limitations of Use: Glumetza is not used for the treatment of type 1 diabetes or ketoacidosis (1). Glumetza carries a boxed warning regarding the risk of lactic acidosis, which may be fatal. Increased risk is associated with hypotensive states such as acute congestive heart failure and acute myocardial infarction. Glumetza is contraindicated in patients with renal impairment, metabolic acidosis or hypersensitivity to metformin hydrochloride. Before initiating therapy with Glumetza, evaluate the patient s renal function (1).
2 Subject: Glumetza Page: 2 of 5 Patients should be warned against excessive alcohol intake while taking Glumetza (1). Hematologic parameters of Vitamin B 12 levels should be measured annually due to the potential of metformin to lower levels (1). Safety and effectiveness in pediatric patients less than 18 years of age have not been established (1). Related policies SGLT2 Inhibitors Policy This policy statement applies to clinical review performed for pre-service (Prior Approval, Precertification, Advanced Benefit Determination, etc.) and/or post-service claims. Glumetza may be considered medically necessary in patients who are 18 years of age and older with type 2 diabetes mellitus. These patients should also have inadequate response, intolerance to all of the following: generic form of Glumetza, generic form of Glucophage ER, and immediate release metformin; patient must have none of the following: renal impairment with serum creatinine levels 1.5 mg/dl for men, 1.4 mg/dl for women or abnormal creatinine clearance, hepatic impairment and metabolic acidosis, including diabetic ketoacidosis. Glumetza is considered investigational in patients that are less than 18 years of age and in patients with any diagnosis other than type 2 diabetes mellitus. Prior-Approval Requirements Age 18 years of age or older Diagnoses Patient must have the following: Diabetes mellitus Type 2 AND the following: 1. Inadequate response or intolerance to ALL of following: a. Generic form of Glumetza b. Generic form of Glucophage ER
3 Subject: Glumetza Page: 3 of 5 c. Immediate release metformin AND NONE of the following: 1. Renal impairment with serum creatinine levels 1.5 mg/dl for men, 1.4 mg/dl for women or abnormal creatinine clearance 2. Hepatic impairment 3. Metabolic acidosis, including diabetic ketoacidosis Prior Approval Renewal Requirements Diagnoses Patient must have the following: Policy Guidelines Diabetes mellitus Type 2 Pre - PA Allowance None Prior - Approval Limits AND the following: 1. Inadequate response or intolerance to the generic form of Glumetza AND NONE of the following: 1. Renal impairment with serum creatinine levels 1.5 mg/dl for men, 1.4 mg/dl for women or abnormal creatinine clearance 2. Hepatic impairment 3. Metabolic acidosis, including diabetic ketoacidosis Quantity 500mg 360 tablets per 90 days OR 1000mg 180 tablets per 90 days Maximum daily limit of any combination: 2000mg Duration 12 months
4 Subject: Glumetza Page: 4 of 5 Prior Approval Renewal Limits Prior - Approval Limits Quantity 500mg 360 tablets per 90 days OR 1000mg 180 tablets per 90 days Maximum daily limit of any combination: 2000mg Duration 12 months Rationale Summary Glumetza is an oral, extended-release formulation of metformin that is indicated to improve glycemic control in adult patients with type 2 diabetes mellitus. Controlling high blood sugar helps prevent kidney damage, blindness, nerve problems, loss of limbs, and sexual function problems. Proper control of diabetes may also lessen your risk of a heart attack or stroke. Metformin works by helping to restore your body's proper response to the insulin you naturally produce. It also decreases the amount of sugar that your liver makes and that your stomach/intestines absorb. Glumetza is administered once daily with the evening meal.the safety and efficacy of Glumetza in pediatric patients has not been established (1). Prior approval is required to ensure the safe, clinically appropriate and cost effective use of Glumetza while maintaining optimal therapeutic outcomes. References 1. Glumetza [package insert]. Raleigh, NC; Salix Pharmaceuticals, Inc. April Policy History Date October 2015 December 2015 February 2016 March 2016 Action Addition to PA Annual review Addition of inadequate response, intolerance to all of the following: generic form of Glumetza, generic form of Glucophage ER. Also addition of the requirement of inadequate response, intolerance to the generic form of Glumetza in the renewal section Annual editorial review
5 Subject: Glumetza Page: 5 of 5 Keywords Policy number change from to This policy was approved by the FEP Pharmacy and Medical Policy Committee on March 18, 2016 and is effective on April 1, Deborah M. Smith, MD, MPH
SGLT2 Inhibitors
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.30.19 Subject: SGLT2 Inhibitors Page: 1 of 6 Last Review Date: September 15, 2016 SGLT2 Inhibitors Description
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Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.08.27 1 of 6 Last Review Date: December 5, 2014 Tysabri Description Tysabri (natalizumab) Background
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Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.60.01 Subject: Tecfidera Page: 1 of 5 Last Review Date: December 2, 2016 Tecfidera Description Tecfidera
More informationBenlysta. Benlysta (belimumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.99.01 Subject: Benlysta Page: 1 of 5 Last Review Date: June 22, 2018 Benlysta Description Benlysta (belimumab)
More informationPage: 1 of 5. Methylphenidate also has an off-label indication for depression, although published trials are limited in size and duration (12).
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.06.25 Page: 1 of 5 Last Review Date: June 19, 2015 Description Concerta / Daytrana / Metadate CD / Metadate
More informationYervoy. Yervoy (ipilimumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.13 Subject: Yervoy Page: 1 of 4 Last Review Date: March 18, 2016 Yervoy Description Yervoy (ipilimumab)
More informationViberzi. Viberzi (eluxadoline) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subsection: Gastrointestinal Agents Original Policy Date: July 24, 2015 Subject: Viberzi Page: 1 of 5 Last
More informationGilotrif. Gilotrif (afatinib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.39 Subject: Gilotrif Page: 1 of 6 Last Review Date: March 16, 2018 Gilotrif Description Gilotrif (afatinib)
More informationXenazine. Xenazine (tetrabenazine) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.60.12 Subject: Xenazine Page: 1 of 5 Last Review Date: December 8, 2017 Xenazine Description Xenazine
More informationSimponi / Simponi ARIA (golimumab)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.51 Subject: Simponi / Simponi ARIA Page: 1 of 6 Last Review Date: September 15, 2016 Simponi / Simponi
More informationSoma (carisoprodol), Soma Compound (carisoprodol and aspirin), Soma Compound w/ Codeine (carisoprodol and aspirin and codeine)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.75.07 Subject: Page: 1 of 7 Last Review Date: September 15, 2016 Description (carisoprodol), Compound
More informationSamsca. Samsca (tolvaptan) Description
Subject: Samsca Page: 1 of 5 Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Last Review Date: September 20, 2018 Samsca Description Samsca (tolvaptan)
More information2. Treatment of patients with metastatic, squamous NSCLC progressing after platinumbased
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.39 Subject: Gilotrif Page: 1 of 5 Last Review Date: June 24, 2016 Gilotrif Description Gilotrif (afatinib)
More informationSensipar. Sensipar (cinacalcet) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.30.46 Subject: Sensipar Page: 1 of 5 Last Review Date: June 22, 2018 Sensipar Description Sensipar (cinacalcet)
More informationRepatha. Repatha (evolocumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.16.08 Subject: Repatha Page: 1 of 8 Last Review Date: September 18, 2015 Repatha Description Repatha
More informationDaklinza Sovaldi. Daklinza (daclatasvir) and Sovaldi (sofosbuvir) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.01.36 Subject: Daklinza Page: 1 of 8 Last Review Date: March 18, 2016 Daklinza Description Daklinza (daclatasvir)
More informationMovantik (naloxegol), Relistor (methylnaltrexone bromide), Symproic (naldemedine)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.50.06 Subject: Opioid Antagonist Drug Class Page: 1 of 5 Last Review Date: June 22, 2017 Opioid Antagonist
More informationSumatriptan Injection (Imitrex / Alsuma / Sumavel / Zembrace)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.11 Subject: Sumatriptan Injection Page: 1 of 6 Last Review Date: March 17, 2017 Sumatriptan Injection
More informationRepatha. Repatha (evolocumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.40.08 Subject: Repatha Page: 1 of 8 Last Review Date: December 2, 2016 Repatha Description Repatha (evolocumab)
More informationZomig. Zomig / Zomig-ZMT (zolmitriptan) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.22 Subject: Zomig Page: 1 of 5 Last Review Date: March 16, 2018 Zomig Description Zomig / Zomig-ZMT
More informationMovantik (naloxegol), Relistor (methylnaltrexone bromide), Symproic (naldemedine)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.50.06 Subject: Opioid Antagonist Drug Class Page: 1 of 7 Last Review Date: November 30, 2018 Opioid Antagonist
More informationOff Label Uses: Amphetamines can be used as adjunctive therapy in the treatment of resistant depression (9).
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.06.24 Subject: Amphetamines Page: 1 of 4 Last Review Date: June 19, 2015 Amphetamines Description Adderall
More informationPromacta. Promacta (eltrombopag) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.85.15 Subject: Promacta Page: 1 of 6 Last Review Date: September 20, 2018 Promacta Description Promacta
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