CRITERIA: UPDL Paramount Advantage (Medicaid) APPROVED: 06/2021 VERIFIED: 072021 REVIEWED: 06/2021 DIABETES HYPOGLYCEMICS ORAL Prior Authorization Override Request PHARMACY FAX # 844-256-2025 • Pertinent office notes and past medical history must be submitted with the prior authorization request.

PATIENT INFORMATION Patient Name Date

Paramount ID DOB Gender: M/F

Medication Allergies

PROVIDER INFORMATION Prescriber Name NPI # DEA #

Prescriber Specialty Prescriber Address

Office Fax Phone Office Contact Name

MEDICATION REQUESTED Drug Name Strength Directions (Sig)

Duration of Therapy: Quantity Diagnosis Days: Months: Are you requesting brand (DAW): _ NO _ YES *PLEASE NOTE DAW REQUESTS REQUIRE RATIONALE- SEE BELOW

Is the Patient currently being treated with this medication?  Yes; Date started mm/dd/yy / /  No

ACTOPLUS MET XR (pioglitazone/metformin) (alogliptin - generic of Nesina) (alogliptin/metformin - generic of Kazano) AVANDIA (rosiglitazone) FARXIGA (dapagliflozin) (glimepiride/pioglitazone - generic of Duetact) GLUCOPHAGE (metformin) GLUCOPHAGE XR (metformin ER) GLUCOVANCE (glyburide/metformin) GLYSET (miglitol) GLYXAMBI (empagliflozin/linagliptin) INVOKANA (canagliflozin) INVOKAMET (canagliflozin/metformin) INVOKAMET XR (canagliflozin/metformin ER) JANUMET (sitagliptin/metformin) JANUMET XR (sitagliptin/metformin) JANUVIA (sitagliptin) JARDIANCE (empagliflozin) JENTADUETO (linagliptin/metformin) JENTADUETO XR (linagliptin/metformin) KOMBIGLYZE XR (saxagliptin/metformin) METAGLIP (glipizide/metformin) (metformin ER – generic of Fortamet) (metformin solution - generic of Riomet) (miglitol - generic of Glyset) ONGLYZA (saxagliptin) (pioglitazone/alogliptin - generic of Oseni) QTERN (dapaglifozin-saxagliptin) SEGLUROMET (ertugliflozin/metformin) STEGLATRO (ertugliflozin) STEGLUJAN (ertugliflozin/sitagliptin) SYNJARDY (empagliflozin/metformin) SYNJARDY XR (empagliflozin/metformin extended release) TRADJENTA (linagliptin) TRIJARDY XR (empagliflozin/linagliptin/metformin) XIGDUO XR (dapagliflozin/metformin)

MEDICAL JUSTIFICATION: Include Other Relevant Medications Tried and Results Please indicate previous treatment and outcomes below Previous Medication Strength Qty Directions (Sig) Dates (mmddyy to mmddyy) Reason for Discontinuation 1

2

3

CRITERIA: UPDL Paramount Advantage (Medicaid) APPROVED: 06/2021 VERIFIED: 072021 REVIEWED: 06/2021 4

CRITERIA FOR APPROVAL

1 Is the request for Farxiga? Yes No [If no, then skip to question 3.]

2 Is the requested drug being prescribed for any of the following: A) Heart Failure Yes No with reduced ejection fraction, B) Chronic Kidney Disease at risk of progression, C) Type 2 diabetes and established cardiovascular disease, D) Type 2 diabetes and multiple cardiovascular disease risk factors? [If yes, then no further questions.] [If no, then skip to question 7.]

3 Is the request for Jardiance? Yes No [If no, then skip to question 5.]

4 Is the requested drug being prescribed for Type 2 diabetes and established Yes No cardiovascular disease? [If yes, then no further questions.] [If no, then skip to question 7.]

5 Is the request for Invokana? Yes No [If no, then skip to question 7.]

6 Is the requested drug being prescribed for any of the following: A) Type 2 Yes No diabetes and established cardiovascular disease, B) Diabetic nephropathy with albuminuria? [If yes, then no further questions.]

7 Is this request for ANY step therapy product, for example: A) Actoplus Met XR, B) Yes No Miglitol, C) Janumet, D) Janumet XR, E) Januvia, F) Jardiance, G) Jentadueto, H) Synjardy, I) Tradjenta, J) Invokana, K) Invokamet, L) Farxiga? [If no, then skip to question 11.]

8 Is the request for continuation of therapy in the past 120 days? Yes No [If no, then skip to question 10.]

9 Has the provider submitted clinical documentation and rationale supporting that Yes No the member’s disease state is currently controlled on the requested medication? [Note: Documentation is required for approval.]

[If yes, then no further questions.]

10 Has the patient experienced an inadequate clinical response to metformin Yes No products (either single-ingredient or in a sulfonylurea/metformin or TZD/metformin combination), including a trial of no less than 60 days of at least ONE preferred metformin product in the past 120 days? [Note: Inadequate clinical response after at least 60 days of the recommended therapeutic dose with documented adherence to the regimen.] [Note: Please submit clinical documentation supporting the trial and failure of preferred medications, including dates and reason for discontinuation.]

CRITERIA: UPDL Paramount Advantage (Medicaid) APPROVED: 06/2021 VERIFIED: 072021 REVIEWED: 06/2021

[If yes, then no further questions.] [If no, then skip to question 14.]

11 Is this request for any of the following: A) Qtern, B) Steglujan, C) Glyxambi? Yes No [If no, then skip to question 13.]

12 Has the patient experienced an inadequate clinical response to no less than a 90 Yes No day trial of at least ONE preferred DPP-4 (dipeptidyl peptidase-4 inhibitor) and SGLT2 (sodium-glucose cotransporter 2 inhibitor) product in the past 120 days? [Note Inadequate clinical response after at least 90 days of the recommended therapeutic dose with documented adherence to the regimen.] [Note: Please submit clinical documentation supporting the trial and failure of preferred medications, including dates and reason for discontinuation.]

[If yes, then no further questions.] [If no, then skip to question 14.]

13 Has the patient experienced an inadequate clinical response to preferred Yes No alternatives, including metformin AND a trial of no less than 60 days of at least ONE preferred or step therapy product in the past 120 days (e.g. must trial preferred within Endocrine Agents: Diabetes—Non-Insulin category)? [Note: Inadequate clinical response after at least 60 days of the recommended therapeutic dose with documented adherence to the regimen.] [Note: Please submit clinical documentation supporting the trial and failure of preferred medications, including dates and reason for discontinuation.]

[If yes, then no further questions.]

14 Is the patient unable to be changed to a preferred medication (which does not Yes No require prior approval) or a preferred step therapy medication within the same class for any of the following acceptable reasons: A) Allergy, B) Contraindication or drug interaction, C) History of unacceptable or toxic side effects? [Note: Please submit clinical documentation supporting why patient is unable to be changed to a preferred medication (e.g. description of allergy/toxic side effects/contraindication.)

RELEVANT MEDICAL RATIONALE FOR REQUEST/ADDITIONAL CLINICAL INFORMATION INCLUDING WHY PATIENT REQUIRES BRAND OVER GENERIC. (Attach Relevant Lab Results and Chart Notes)*

*In order to process this request, please complete all boxes completely.

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