Diabetes, DPP-4 Inhibitors

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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.

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Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria Carveout
‐ Bill FFS		 New Drug Evaluation & Updates
saxagliptin HCl ONGLYZA TABLET Y Pharmacy PA N  
sitagliptin phos/metformin HCl JANUMET TABLET Y Pharmacy PA N  
alogliptin benz/metformin HCl KAZANO TABLET N Pharmacy PA N  
alogliptin benz/metformin HCl ALOGLIPTIN-METFORMIN TABLET N Pharmacy PA N  
alogliptin benz/pioglitazone OSENI TABLET N Pharmacy PA N  
alogliptin benzoate NESINA TABLET N Pharmacy PA N  
linagliptin/metformin HCl JENTADUETO TABLET N Pharmacy PA N  
saxagliptin HCl/metformin HCl KOMBIGLYZE XR TBMP 24HR N Pharmacy PA N  
sitagliptin HCl BRYNOVIN SOLUTION N Pharmacy PA N  
sitagliptin/metformin HCl SITAGLIPTIN-METFORMIN TABLET N Pharmacy PA N  
sitagliptin/metformin HCl ZITUVIMET TABLET N Pharmacy PA N  
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