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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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
45802021172 ALOGLIPTIN-METFORMIN alogliptin benz/metformin HCl TABLET 12.5 mg-1,000 mg N Y N Pharmacy PA
64764033760 KAZANO alogliptin benz/metformin HCl TABLET 12.5 mg-1,000 mg N Y N Pharmacy PA
45802016972 ALOGLIPTIN-METFORMIN alogliptin benz/metformin HCl TABLET 12.5 mg-500 mg N Y N Pharmacy PA
64764033560 KAZANO alogliptin benz/metformin HCl TABLET 12.5 mg-500 mg N Y N Pharmacy PA
45802026065 ALOGLIPTIN-PIOGLITAZONE alogliptin benz/pioglitazone TABLET 12.5 mg-30 mg N Y N Pharmacy PA
45802035165 ALOGLIPTIN-PIOGLITAZONE alogliptin benz/pioglitazone TABLET 25 mg-15 mg N Y N Pharmacy PA
45802040265 ALOGLIPTIN-PIOGLITAZONE alogliptin benz/pioglitazone TABLET 25 mg-30 mg N Y N Pharmacy PA
64764025303 OSENI alogliptin benz/pioglitazone TABLET 25 mg-30 mg N Y N Pharmacy PA
45802049965 ALOGLIPTIN-PIOGLITAZONE alogliptin benz/pioglitazone TABLET 25 mg-45 mg N Y N Pharmacy PA
45802010365 ALOGLIPTIN alogliptin benzoate TABLET 12.5 mg N Y N Pharmacy PA
64764012530 NESINA alogliptin benzoate TABLET 12.5 mg N Y N Pharmacy PA
45802015065 ALOGLIPTIN alogliptin benzoate TABLET 25 mg N Y N Pharmacy PA
64764025030 NESINA alogliptin benzoate TABLET 25 mg N Y N Pharmacy PA
45802008765 ALOGLIPTIN alogliptin benzoate TABLET 6.25 mg N Y N Pharmacy PA
00597014030 TRADJENTA linagliptin TABLET 5 mg N Y N Pharmacy PA
00597014061 TRADJENTA linagliptin TABLET 5 mg N Y N Pharmacy PA
00597014070 TRADJENTA linagliptin TABLET 5 mg N Y N Pharmacy PA
00597014090 TRADJENTA linagliptin TABLET 5 mg N Y N Pharmacy PA
00597027073 JENTADUETO XR linagliptin/metformin HCl TAB BP 24H 2.5 mg-1,000 mg N Y N Pharmacy PA
00597027094 JENTADUETO XR linagliptin/metformin HCl TAB BP 24H 2.5 mg-1,000 mg N Y N Pharmacy PA
00597027533 JENTADUETO XR linagliptin/metformin HCl TAB BP 24H 5 mg-1,000 mg N Y N Pharmacy PA
00597027581 JENTADUETO XR linagliptin/metformin HCl TAB BP 24H 5 mg-1,000 mg N Y N Pharmacy PA
00597014818 JENTADUETO linagliptin/metformin HCl TABLET 2.5 mg-1,000 mg N Y N Pharmacy PA
00597014860 JENTADUETO linagliptin/metformin HCl TABLET 2.5 mg-1,000 mg N Y N Pharmacy PA
00597014618 JENTADUETO linagliptin/metformin HCl TABLET 2.5 mg-500 mg N Y N Pharmacy PA
00597014660 JENTADUETO linagliptin/metformin HCl TABLET 2.5 mg-500 mg N Y N Pharmacy PA
00597014718 JENTADUETO linagliptin/metformin HCl TABLET 2.5 mg-850 mg N Y N Pharmacy PA
00597014760 JENTADUETO linagliptin/metformin HCl TABLET 2.5 mg-850 mg N Y N Pharmacy PA
00310610030 ONGLYZA saxagliptin HCl TABLET 2.5 mg Y Y N Pharmacy PA
00378470577 SAXAGLIPTIN HCL saxagliptin HCl TABLET 2.5 mg Y Y N Pharmacy PA
00378470593 SAXAGLIPTIN HCL saxagliptin HCl TABLET 2.5 mg Y Y N Pharmacy PA
65162005903 SAXAGLIPTIN HCL saxagliptin HCl TABLET 2.5 mg Y Y N Pharmacy PA
65862082530 SAXAGLIPTIN HCL saxagliptin HCl TABLET 2.5 mg Y Y N Pharmacy PA
65862082590 SAXAGLIPTIN HCL saxagliptin HCl TABLET 2.5 mg Y Y N Pharmacy PA
68462072630 SAXAGLIPTIN HCL saxagliptin HCl TABLET 2.5 mg Y Y N Pharmacy PA
68462072690 SAXAGLIPTIN HCL saxagliptin HCl TABLET 2.5 mg Y Y N Pharmacy PA
00310610530 ONGLYZA saxagliptin HCl TABLET 5 mg Y Y N Pharmacy PA
00310610590 ONGLYZA saxagliptin HCl TABLET 5 mg Y Y N Pharmacy PA
00378470677 SAXAGLIPTIN HCL saxagliptin HCl TABLET 5 mg Y Y N Pharmacy PA
00378470693 SAXAGLIPTIN HCL saxagliptin HCl TABLET 5 mg Y Y N Pharmacy PA
65162006003 SAXAGLIPTIN HCL saxagliptin HCl TABLET 5 mg Y Y N Pharmacy PA
65862082630 SAXAGLIPTIN HCL saxagliptin HCl TABLET 5 mg Y Y N Pharmacy PA
65862082690 SAXAGLIPTIN HCL saxagliptin HCl TABLET 5 mg Y Y N Pharmacy PA
68462072730 SAXAGLIPTIN HCL saxagliptin HCl TABLET 5 mg Y Y N Pharmacy PA
68462072790 SAXAGLIPTIN HCL saxagliptin HCl TABLET 5 mg Y Y N Pharmacy PA
00310612560 KOMBIGLYZE XR saxagliptin HCl/metformin HCl TBMP 24HR 2.5 mg-1,000 mg N Y N Pharmacy PA
00378817691 SAXAGLIPTIN-METFORMIN ER saxagliptin HCl/metformin HCl TBMP 24HR 2.5 mg-1,000 mg N Y N Pharmacy PA
43598061860 SAXAGLIPTIN-METFORMIN ER saxagliptin HCl/metformin HCl TBMP 24HR 2.5 mg-1,000 mg N Y N Pharmacy PA
00310614530 KOMBIGLYZE XR saxagliptin HCl/metformin HCl TBMP 24HR 5 mg-1,000 mg N Y N Pharmacy PA
00378817793 SAXAGLIPTIN-METFORMIN ER saxagliptin HCl/metformin HCl TBMP 24HR 5 mg-1,000 mg N Y N Pharmacy PA
43598061930 SAXAGLIPTIN-METFORMIN ER saxagliptin HCl/metformin HCl TBMP 24HR 5 mg-1,000 mg N Y N Pharmacy PA
00310613530 KOMBIGLYZE XR saxagliptin HCl/metformin HCl TBMP 24HR 5 mg-500 mg N Y N Pharmacy PA
00378817593 SAXAGLIPTIN-METFORMIN ER saxagliptin HCl/metformin HCl TBMP 24HR 5 mg-500 mg N Y N Pharmacy PA
43598062030 SAXAGLIPTIN-METFORMIN ER saxagliptin HCl/metformin HCl TBMP 24HR 5 mg-500 mg N Y N Pharmacy PA
70710190103 SITAGLIPTIN sitagliptin TABLET 100 mg N Y N Pharmacy PA
70710190109 SITAGLIPTIN sitagliptin TABLET 100 mg N Y N Pharmacy PA
70710124203 ZITUVIO sitagliptin TABLET 100 mg N Y N Pharmacy PA
70710189903 SITAGLIPTIN sitagliptin TABLET 25 mg N Y N Pharmacy PA
70710189909 SITAGLIPTIN sitagliptin TABLET 25 mg N Y N Pharmacy PA
70710124003 ZITUVIO sitagliptin TABLET 25 mg N Y N Pharmacy PA
70710190003 SITAGLIPTIN sitagliptin TABLET 50 mg N Y N Pharmacy PA
70710190009 SITAGLIPTIN sitagliptin TABLET 50 mg N Y N Pharmacy PA
70710124103 ZITUVIO sitagliptin TABLET 50 mg N Y N Pharmacy PA
24338001701 BRYNOVIN sitagliptin HCl SOLUTION 25 mg/mL N Y N Pharmacy PA
00006057761 JANUMET sitagliptin phos/metformin HCl TABLET 50 mg-1,000 mg Y Y N Pharmacy PA
00006057762 JANUMET sitagliptin phos/metformin HCl TABLET 50 mg-1,000 mg Y Y N Pharmacy PA
00006057782 JANUMET sitagliptin phos/metformin HCl TABLET 50 mg-1,000 mg Y Y N Pharmacy PA
00006057561 JANUMET sitagliptin phos/metformin HCl TABLET 50 mg-500 mg Y Y N Pharmacy PA
00006057562 JANUMET sitagliptin phos/metformin HCl TABLET 50 mg-500 mg Y Y N Pharmacy PA
00006057582 JANUMET sitagliptin phos/metformin HCl TABLET 50 mg-500 mg Y Y N Pharmacy PA
00006008131 JANUMET XR sitagliptin phos/metformin HCl TBMP 24HR 100 mg-1,000 mg N Y N Pharmacy PA
00006008154 JANUMET XR sitagliptin phos/metformin HCl TBMP 24HR 100 mg-1,000 mg N Y N Pharmacy PA
00006008182 JANUMET XR sitagliptin phos/metformin HCl TBMP 24HR 100 mg-1,000 mg N Y N Pharmacy PA
00006008061 JANUMET XR sitagliptin phos/metformin HCl TBMP 24HR 50 mg-1,000 mg N Y N Pharmacy PA
00006008062 JANUMET XR sitagliptin phos/metformin HCl TBMP 24HR 50 mg-1,000 mg N Y N Pharmacy PA
00006008082 JANUMET XR sitagliptin phos/metformin HCl TBMP 24HR 50 mg-1,000 mg N Y N Pharmacy PA
00006007861 JANUMET XR sitagliptin phos/metformin HCl TBMP 24HR 50 mg-500 mg N Y N Pharmacy PA
00006007862 JANUMET XR sitagliptin phos/metformin HCl TBMP 24HR 50 mg-500 mg N Y N Pharmacy PA
00006007882 JANUMET XR sitagliptin phos/metformin HCl TBMP 24HR 50 mg-500 mg N Y N Pharmacy PA
00006027701 JANUVIA sitagliptin phosphate TABLET 100 mg Y Y N Pharmacy PA
00006027728 JANUVIA sitagliptin phosphate TABLET 100 mg Y Y N Pharmacy PA
00006027731 JANUVIA sitagliptin phosphate TABLET 100 mg Y Y N Pharmacy PA
00006027754 JANUVIA sitagliptin phosphate TABLET 100 mg Y Y N Pharmacy PA
00006027782 JANUVIA sitagliptin phosphate TABLET 100 mg Y Y N Pharmacy PA
00006022101 JANUVIA sitagliptin phosphate TABLET 25 mg Y Y N Pharmacy PA
00006022128 JANUVIA sitagliptin phosphate TABLET 25 mg Y Y N Pharmacy PA
00006022131 JANUVIA sitagliptin phosphate TABLET 25 mg Y Y N Pharmacy PA
00006022154 JANUVIA sitagliptin phosphate TABLET 25 mg Y Y N Pharmacy PA
00006011201 JANUVIA sitagliptin phosphate TABLET 50 mg Y Y N Pharmacy PA
00006011228 JANUVIA sitagliptin phosphate TABLET 50 mg Y Y N Pharmacy PA
00006011231 JANUVIA sitagliptin phosphate TABLET 50 mg Y Y N Pharmacy PA
00006011254 JANUVIA sitagliptin phosphate TABLET 50 mg Y Y N Pharmacy PA
70710198706 SITAGLIPTIN-METFORMIN sitagliptin/metformin HCl TABLET 50 mg-1,000 mg N Y N Pharmacy PA
70710178706 ZITUVIMET sitagliptin/metformin HCl TABLET 50 mg-1,000 mg N Y N Pharmacy PA
70710198606 SITAGLIPTIN-METFORMIN sitagliptin/metformin HCl TABLET 50 mg-500 mg N Y N Pharmacy PA
70710178606 ZITUVIMET sitagliptin/metformin HCl TABLET 50 mg-500 mg N Y N Pharmacy PA
70710203803 SITAGLIPTIN-METFORMIN ER sitagliptin/metformin HCl TBMP 24HR 100 mg-1,000 mg N Y N Pharmacy PA
70710180603 ZITUVIMET XR sitagliptin/metformin HCl TBMP 24HR 100 mg-1,000 mg N Y N Pharmacy PA
70710203706 SITAGLIPTIN-METFORMIN ER sitagliptin/metformin HCl TBMP 24HR 50 mg-1,000 mg N Y N Pharmacy PA
70710180506 ZITUVIMET XR sitagliptin/metformin HCl TBMP 24HR 50 mg-1,000 mg N Y N Pharmacy PA
70710203606 SITAGLIPTIN-METFORMIN ER sitagliptin/metformin HCl TBMP 24HR 50 mg-500 mg N Y N Pharmacy PA
70710180406 ZITUVIMET XR sitagliptin/metformin HCl TBMP 24HR 50 mg-500 mg N Y N Pharmacy PA
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