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Metformin – Extended-Release Products - NC Standard

Commercial Policy
Version Date: June 2023

Restricted Product(s)

Restriction applies to brand and generic products

  • Fortamet® (metformin ER osmotic release) 
  • Glumetza® (metformin ER modified release)

FDA Approved Use

  • For adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.

Criteria for Approval of Restricted Product(s)

  1. The patient has a diagnosis of type 2 diabetes mellitus; AND 
  2. The patient is requesting metformin ER osmotic release (Fortamet)/ brand Fortamet; AND 
    1. The patient has tried and failed or has a clinical contraindication/intolerance to metformin ER (Glucophage XR); OR 
  3. The patient is requesting metformin ER modified release (Glumetza)/brand Glumetza; AND 
    1. The patient has tried and failed or has a clinical contraindication/intolerance to metformin ER (Glucophage XR); AND 
    2. The patient has tried and failed or has a clinical contraindication/intolerance to metformin ER osmotic release (Fortamet); AND 
  4. For formularies that exclude (non-formulary) the requested medication, Non-formulary Exception Criteria applies.

Duration of Approval: 365 days (1 year) 

References

All information referenced is from FDA package insert unless otherwise noted below.

Policy Implementation/Update Information

Criteria and treatment protocols are reviewed annually by the Blue Cross NC P&T Committee, regardless of change. This policy is reviewed in Q2 annually.

June 2023: Criteria update: Formatting changes only.

Feb 2022: Criteria update: Annual criteria review. Updated duration of approval to 1 year.

Nov 2020: Criteria update: Annual criteria review. Formatting changes only.

Mar 2019: Added Net Results to policy – combined all formularies into one policy. Updated duration of approval to 3 years.

Jan 2018: Restriction on brand and generic Fortamet extended to the Enhanced formulary

Oct 2017: Restrictions added to brand and generic Fortamet on the Essential formulary

May 2016: Original utilization management criteria issued

Disclosures:

BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross NC is an independent licensee of the Blue Cross and Blue Shield Association. All other marks are the property of their respective owners.

Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.

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