Diabetes, Miscellaneous Antidiabetic Agents
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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.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| metformin HCl | METFORMIN HCL ER | TAB ER 24H | Y | N | ||
| metformin HCl | METFORMIN HCL | TABLET | Y | N | ||
| acarbose | ACARBOSE | TABLET | N | N | ||
| glipizide/metformin HCl | GLIPIZIDE-METFORMIN | TABLET | N | N | ||
| glyburide/metformin HCl | GLYBURIDE-METFORMIN HCL | TABLET | N | N | ||
| metformin HCl | METFORMIN HCL | SOLUTION | N | N | ||
| metformin HCl | METFORMIN ER OSMOTIC | TAB ER 24 | N | N | ||
| metformin HCl | METFORMIN ER GASTRIC | TABERGR24H | N | N | ||
| metformin HCl | METFORMIN HCL | TABLET | N | N | ||
| miglitol | MIGLITOL | TABLET | N | N | ||
| nateglinide | NATEGLINIDE | TABLET | N | N | ||
| pramlintide acetate | SYMLINPEN 120 | PEN INJCTR | N | N | ||
| pramlintide acetate | SYMLINPEN 60 | PEN INJCTR | N | N | ||
| repaglinide | REPAGLINIDE | TABLET | N | N | ||
| teplizumab-mzwv | TZIELD | VIAL | N | Pharmacy PA | N | Apr 06, 2023 |
| metformin HCl | METFORMIN HCL | TABLET | N |