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Diabetes Value Program – Enhanced
| Restricted Non-preferred Product(s) | Unrestricted/Suggested Alternative(s) |
|---|---|
| Basaglar® (insulin glargine) | Lantus® (insulin glargine) Toujeo® (insulin glargine) Levemir® (insulin detemir) Tresiba® (insulin degludec) |
| SymlinPen® (pramlintide injection) | Novolin/Novolog® (insulin isophane) |
Byetta® (exenatide) Bydureon® (exenatide) Adlyxin® (lixisenatide) | Ozempic® (semaglutide) Trulicity® (dulaglutide) Victoza® (liraglutide) |
Aloglipitin Nesina® (aloglipitin) Cycloset® | Januvia® (sitagliptin) Onglyza® (saxagliptin) Invokana® (canagliflozin) Jardiance® (empagliflozin) |
Alogliptin/metformin Kazano® (alogliptin/metformin) Alogliptin/pioglitazone Oseni® (alogliptin/pioglitazone) Steglujan® (ertugliflozin/sitagliptin) | Invokamet XR® (canagliflozin/metformin) Janumet XR® (sitagliptin/metformin) Kombiglyze XR® (saxagliptin/metformin) Synjardy® (empagliflozin/metformin) Synjardy XR® (empagliflozin/metformin) |
| Riomet® (metformin oral solution) | Metformin (Glucophage, Glucophage XR) |
Rationale:
The unrestricted products above, treat the same condition at a lower cost for members.
Criteria Summary:
Trial of effective and lower cost agent; exception to quantity limitation.
Criteria for Approval of Restricted Product(s):
- The request is for coverage of Riomet: AND
- The patient is unable to take a take a tablet formulation of metformin; AND
- The patient is not taking a tablet or capsule formulation of another medication; OR
- The request is for coverage of SymlinPen; AND
- The patient is currently taking mealtime insulin; AND
- The patient cannot safely increase (optimize) their meal time insulin; OR
- The request is for coverage of any other restricted medication; AND
- The patient has had a trial and failure of TWO of the corresponding alternatives listed in the chart above; OR
- The patient has a clinical contraindication/ intolerance to all of the corresponding alternatives listed in the chart above.
Duration of Approval: 1095 days (3 years)
Quantity Limitations:
Quantity limitations apply to brand and associated generic products*
| Medication | Quantity per Day (Unless Specified) |
|---|---|
| Adlyxin® (lixisenatide) 50 mcg/mL prefilled pen | 2 pens every 28 days |
| Adlyxin® (lixisenatide) 100 mcg/mL prefilled pen | 2 pens every 28 days |
| Basaglar Kwikpen® (insulin glargine) 3 mL pen | 100 mL every 30 days |
| Bydureon® (exenatide ER) 2 mg/vial/pen | 1 carton (4 trays/4 doses) per 28 days |
| Bydureon BCis™ (exenatide ER) 2 mg/pen | 4 pens every 28 days |
| Byetta® (exenatide) 5 mcg/dose prefilled pen | 1 prefilled pen (60 doses) every 30 days |
| Byetta® (exenatide) 10 mcg/dose prefilled pen | 1 prefilled pen (60 doses) every 30 days |
| Kazano® (alogliptin/metformin) 12.5mg/500mg tablet | 2 tablets |
| Kazano® (alogliptin/metformin) 12.5mg/1000mg table | 2 tablets |
| Nesina (alogliptin) 6.25mg tablet | 1 tablet |
| Nesina (alogliptin) 12.5mg tablet | 1 tablet |
| Nesina (alogliptin) 25mg tablet | 1 tablet |
| Oseni® (alogliptin/pioglitazone) 12.5mg/15mg tablet | 1 tablet |
| Oseni® (alogliptin/pioglitazone) 12.5mg/30mg tablet | 1 tablet |
| Oseni® (alogliptin/pioglitazone) 12.5mg/45mg tablet | 1 tablet |
| Oseni® (alogliptin/pioglitazone) 25mg/15mg tablet | 1 tablet |
| Oseni® (alogliptin/pioglitazone) 25mg/30mg tablet | 1 tablet |
| Oseni® (alogliptin/pioglitazone) 25mg/45mg tablet | 1 tablet |
| Steglujan (ertugliflozin/sitagliptin) 5-100 mg | 1 tablet |
| Steglujan (ertugliflozin/sitagliptin) 15-100 mg | 1 tablet |
Quantity Limit Exception Criteria:
- The quantity (dose) requested is for documented titration purposes at the initiation of therapy (authorization for a 90 day titration period); AND
- The prescribed dose cannot be achieved using a lesser quantity of a higher strength; AND
- The quantity (dose) requested does not exceed the maximum FDA labeled dose, when specified, or to the safest studied dose per the manufacturer’s product insert; OR
- If the quantity (dose) requested exceeds the maximum FDA labeled dose, when specified, or to the safest studied dose per the manufacturer’s product insert, then the prescriber must submit documentation in support of therapy with a higher dose for the intended diagnosis (submitted documentation may include medical records OR fax form which reflects medical record documentation that shows the length of time the requested dose has been used, and what other medications and doses have been tried and failed).
Duration of Approval: 1095 days (3 years)
References:
All information referenced is from FDA package insert unless otherwise noted below.
Policy Implementation/Update Information:
Originated: April 2019; Last updated: July 2019
July 2019: Adlyxin and Steglujan added to policy.
April 2019: Original utilization management criteria issued.
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