Diabetes, DPP-4 Inhibitors
PDL Reference Documents
Newsletters
- September 2020 - Cardiovascular Outcomes Associated with Newer Therapy Classes for Type 2 Diabetes Mellitus
- September 2018 - Management Strategies for Patients with Prediabetes
- March 2016 - Antidiabetic Treatments and Cardiovascular Implications
- February 2016 - 2015 in Review: Relevant Safety Updates and Ongoing Safety Concerns
- October 2013 - Updates and Comparisons of Type 2 Diabetes Treatment Guidelines
- June 2012 - Can The Diabetic War Be Fought By Aggressive Blood Pressure Control?
PDL Status Values
Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the
Non-Preferred Drugs in Select PDL Classes prior authorization criteria.
New drugs will be listed as N until reviewed by the P&T Committee and are subject to the
New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.
To request a Prior Authorization, please use this form.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | New Drug Evaluation |
|---|---|---|---|---|---|
| saxagliptin HCl | SAXAGLIPTIN HCL | TABLET | Y | PA Document | |
| saxagliptin HCl | ONGLYZA | TABLET | Y | PA Document | |
| sitagliptin phos/metformin HCl | JANUMET | TABLET | Y | PA Document | |
| sitagliptin phosphate | JANUVIA | TABLET | Y | PA Document | |
| alogliptin benz/metformin HCl | ALOGLIPTIN-METFORMIN | TABLET | N | PA Document | |
| alogliptin benz/metformin HCl | KAZANO | TABLET | N | PA Document | |
| alogliptin benz/pioglitazone | OSENI | TABLET | N | PA Document | |
| alogliptin benz/pioglitazone | ALOGLIPTIN-PIOGLITAZONE | TABLET | N | PA Document | |
| alogliptin benzoate | NESINA | TABLET | N | PA Document | |
| alogliptin benzoate | ALOGLIPTIN | TABLET | N | PA Document | |
| linagliptin | TRADJENTA | TABLET | N | PA Document | Apr 26, 2012 |
| linagliptin/metformin HCl | JENTADUETO XR | TAB BP 24H | N | PA Document | |
| linagliptin/metformin HCl | JENTADUETO | TABLET | N | PA Document | |
| saxagliptin HCl/metformin HCl | KOMBIGLYZE XR | TBMP 24HR | N | PA Document | |
| saxagliptin HCl/metformin HCl | SAXAGLIPTIN-METFORMIN ER | TBMP 24HR | N | PA Document | |
| sitagliptin | ZITUVIO | TABLET | N | PA Document | |
| sitagliptin phos/metformin HCl | JANUMET XR | TBMP 24HR | N | PA Document | |
| sitagliptin | SITAGLIPTIN | TABLET | PA Document |