Prior Auth Protocol

Prior Authorization Protocol

GLUMETZA^R (metformin hydrochloride extended-release)

NATL

Coverage of drugs is first determined by the member’s pharmacy or medical benefit. Please consult with or refer to the Evidence of Coverage document.

FDA Approved Indications:
- An adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.
Health Net Approved Indications and Usage Guidelines:
- Diagnosis of type 2 diabetes
AND
- Failure or clinically significant adverse effects to metformin AND generic Glucophage XR AND generic Fortamet
Coverage is Not Authorized For:
- Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature.
General Information:
- Generic Glucophage XR (GPI 27250050007520 or 27250050007530) and generic Fortamet (GPI 27250050007560 or 27250050007570) are identified with different GPI 14. Glucophage XR uses dual hydrophilic polymer matrix systems, Fortamet uses single-composition osmotic technology, and Glumetza uses gastric retention technology.

Therapeutic Alternatives:

Drug	Dosing Regimen	Dose Limit/ Maximum Dose
metformin (Glucophage^R)	500 mg BID or 850 mg PO QD, titrate up to 2,550 mg/day	2,550 mg/day
metformin ER (Glucophage^R XR, Fortamet)	500 mg PO QD, increase up to 2,000 mg/day	2,000 mg/day

* Requires Prior Authorization

Recommended Dosing Regimen and Authorization Limit:

Drug Dosing Regimen Authorization Limit
Glumetza
1000 mg PO QD, increase up to 2000 mg/day
Length of Benefit
Product Availability:

Extended-release tablets: 500 mg, 1000 mg
References:

1. Glumetza [Prescribing information] Raleigh, NC: Salix Pharmaceuticals, Inc.; September 2014.
2. Micromedex^R Healthcare Series [Internet Database]. Greenwood Village, Colo: Truven Health Analytics. Updated periodically. Accessed July 2015.

Drug	Dosing Regimen	Authorization Limit
Glumetza	1000 mg PO QD, increase up to 2000 mg/day	Length of Benefit

The material provided to you are guidelines used by this plan to authorize, modify or determine coverage for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.