DIABETES RECOMMENDATIONS AND TIER COVERAGE CHART

DIABETES RECOMMENDATIONS AND

TIER COVERAGE CHART

1 of 6 4/2020

The American Diabetes Association guidelines for 2020, recommend metformin as the preferred initial treatment for type 2 diabetes (T2DM) along with weight

management and physical activity. In patients who have established ASVD or at high risk, CKD, or HF, a SGLT2i or GLP-1 receptor with proven efficacy is recommended

independent of A1C.

• ASCVD dominates:

o GLP-1RA with proven CVD benefit (dulaglutide, liraglutide, injectable semaglutide) OR

o SGLT2i with proven CVD benefit (canagliflozin, empagliflozin) if adequate eGFR

• HF or CKD dominates:

o SGLT2i with evidence of reducing HF and/or CKD progression (empagliflozin, canagliflozin, dapagliflozin) if adequate eGFR OR

o If SGLT2i intolerant/contraindicated or eGFR is inadequate, then GLP-1RA with proven CVD benefit

In individuals without established cardiovascular disease, pharmacological treatment should be patient-centered taking into account side-effects, cost, impact on

weight, risk of hypoglycemia, and other patient preferences. For more detailed information regarding ADA recommendations for pharmacological agents to treat T2DM

click here.

The following chart is a list of oral and injectable diabetes medications listed by class with their respective A1C reduction and insurance coverage and/or coverage

requirements for BCBS, HPHC, Tufts, TMP, and MassHealth.

Medications

BCBSMA

HPHC

Tufts

Tufts Medicare

Preferred

MassHealth

Biguanides

A1C reduction: 1-1.5%

metformin

Tier 1

Tier 1;2

Tier 1

Covered

Glucoghage (metformin)

NC

NC;Tier 3

NC

PA

metformin ER

Tier 1;2

Tier 1

Covered

Gluophage XR (metformin extended release)

NC

NC;Tier 3

NC

PA

metformin solution

-

Tier 1;2

-

PA

Riomet solution

Tier 2;3;4

Tier 3;4

Tier 3; (-)

Tier 3

PA > 13 years

(Brand preferred)

Riomet ER solution

-

Tier 3;4

-

NC

-

DIABETES RECOMMENDATIONS AND

TIER COVERAGE CHART

2 of 6 4/2020

Medications

BCBSMA

HPHC

Tufts

Tufts Medicare

Preferred

MassHealth

metformin extended release (modified)

NC

PA

(Tier 2;3 once approved)

NC

PA

Glumetza (metformin, modified release)

NC

PA

metformin extended release (osmotic)

NC

Premium Formulary: Tier

1;2

Value Formulary: Tier

1;2;3;4 (depends on

strength)

PA

(Tier 3 once approved)

NC

PA

Fortamet (metformin, osmotic release)

NC

PA

Sodium-glucose co-transporter 2 Inhibitors (SGLT2)

A1C reduction: 0.5-1%

Jardiance (empagliflozin)

Tier 2;3 (ST)

Tier 2;3

Tier 2

Tier 3

Covered

Invokana (canagliflozin)

Tier 2;3 (ST)

Tier 2;3

NC

Covered

Farxiga (dapagliflozin)

NC

Tier 3;4

NC

Tier 3

Covered

Steglatro (ertugliflozin)*

NC

Tier 3;4

NC

PA

Glucagon-like Peptide-1 (GLP-1) Receptor Agonists**

A1C reduction: 1-1.5%

Trulicity (dulaglutide)

Tier 2;3 (ST)

Tier 2

Tier 3

PA

Ozempic (semaglutide)

NC

Tier 2;3 (ST)

Tier 2

Tier 3

PA

Rybelsus (oral semaglutide)

NC

-

Victoza (liraglutide)

NC

Tier 2;3 (ST)

Tier 2

Tier 3

PA

Bydureon (exenatide extended release)

Tier 2;3 (ST)

NC

Tier 3

Covered

Bydureon BCise

Tier 2;3 (ST)

NC

Tier 3

PA

Byetta (exenatide)

Tier 2;3 (ST)

NC

Tier 4

Covered

(Brand preferred)

Adlyxin (lixisenatide)

NC

Premium Formulary: Tier

3;4 (ST)

Value Formulary: NC

NC

PA

DIABETES RECOMMENDATIONS AND

TIER COVERAGE CHART

3 of 6 4/2020

Medications

BCBSMA

HPHC

Tufts

Tufts Medicare

Preferred

MassHealth

Long-acting Insulin/Glucagon-like Peptide-1 (GLP-1) Receptor Agonists

A1C reduction: 0.5-1% versus insulin alone

Xultophy (insulin degludec/liraglutide)

NC

PA

(Tier 3;4 once approved)

NC

PA

Soliqua (insulin glargine/lixisenatide)

NC

Premium Formulary: PA

(Tier 3;4 once approved)

Value Formulary: NC

NC

PA

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

A1C reduction: 0.5-1%

Januvia (sitagliptin)

Tier 2;3 (ST)

Tier 2;3

Tier 2

Tier 3

Covered

Tradjenta (linagliptin)

NC

Tier 2;3

NC

Tier 3

Covered

alogliptin

NC

Premium Formulary: NC

Value Formulary:

Tier 3;4;5 (ST)

Tier 1

NC

PA

Nesina (alogliptin)

NC

PA

Onglyza (saxagliptin)

Tier 2;3 (ST)

NC

Covered

Sulfonylureas

A1C reduction: 1-1.5%

glimepiride

Tier 1

Tier 1;2

Tier 1

PA

(Tier 1 once approved)

Covered

Amaryl (glimepiride)

Tier 2;3;4

NC

Tier 3

NC

PA

glipizide

Tier 1

Covered

Glucotrol (glipizide)

Tier 2;3;4

NC

Tier 3

NC

PA

glipizide ER/XL extended release

Tier 1;2

Tier 1

Covered

Glucotrol XL (glipizide extended release)

Tier 2;3;4

NC

Tier 3

NC

PA

DIABETES RECOMMENDATIONS AND

TIER COVERAGE CHART

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Medications

BCBSMA

HPHC

Tufts

Tufts Medicare

Preferred

MassHealth

glyburide

Tier 1;2

Tier 1

PA

(Tier 2 once approved)

Covered

glyburide micronized tablets

Tier 1;2

Tier 1

PA

(Tier 1 once approved)

Covered

Glynase Prestab (glyburide micronized tablets)

Tier 2;3;4

NC

Tier 3

NC

PA

Meglitinides

A1C reduction: 0.5-1%

repaglinide

Tier 1;2

Tier 1

Covered

nateglinide

Tier 1;2

Tier 1

Tier 3

Covered

Starlix (nateglinide)

Tier 2;3;4

NC

Tier 3

NC

PA

Thiazolidinediones

A1C reduction: 1-1.5%

pioglitazone

Tier 1;2 (ST)

Tier 1;2

Tier 1

Covered

Actos (pioglitazone)

Tier 2;3;4 (ST)

NC

Tier 3

NC

PA

Avandia (rosiglitazone)

Tier 2;3;4; (ST)

Tier 3;4

NC

PA

Alpha-Glucosidase Inhibitors

A1C reduction: 0.5-1%

acarbose

Tier 1;2

Tier 1

Covered

Precose (acarbose)

Tier 2;3

NC

Tier 3

NC

PA

miglitol

Tier 1;2

Tier 2

Tier 3

Covered

Glyset (miglitol)

Tier 2;3;4

NC

Tier 3

NC

PA

Miscellaneous

A1C reduction: 0.5%

Cycloset (bromocriptine)

Tier 2;3;4

Tier 2;3

Tier 2

Tier 3

PA

DIABETES RECOMMENDATIONS AND

TIER COVERAGE CHART

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Medications

BCBSMA

HPHC

Tufts

Tufts Medicare

Preferred

MassHealth

colesevelam

Tier 1;2

Tier 2;3

Tier 2

Tier 3

PA

Welchol (colesevelam)

NC

Covered

(Brand preferred)

SymlinPen (pramlintide)

Tier 2;3

Tier 3

PA

Combination Products

metformin/glipizide

Tier 1;2

Tier 1

Covered

metformin/glyburide

Tier 1;2

Tier 1

PA

(Tier 2 once approved)

Covered

metformin/repaglinide

Tier 1;2

NC

Tier 1

NC

PA

pioglitazone/metformin

Tier 1;2 (ST)

Tier 1;2

Tier 1

Tier 3

PA

Actoplus Met (pioglitazone/metformin)

Tier 2;3;4 (ST)

NC

Tier 3

NC

PA

Actoplus Met XR

(pioglitazone/metformin extended release)

Tier 2;3;4 (ST)

NC

Tier 3

NC

PA

alogliptin/metformin

NC

Tier 1

NC

PA

Kazano (alogliptin/metformin)

NC

PA

Janumet (sitagliptin/metformin)

Tier 2;3 (ST)

Tier 2;3

Tier 2

Tier 3

Covered

Janumet XR (sitagliptin/metformin extended release)

Tier 2;3 (ST)

Tier 2;3

Tier 2

Tier 3

Covered

Jentadueto (linagliptin/metformin)

NC

Tier 2;3

NC

Tier 3

Covered

Jentadueto XR (linagliptin/metformin extended release)

NC

Tier 2;3

NC

Tier 3

PA

Kombiglyze XR (saxagliptin/metformin extended release)

Tier 2;3 (ST)

NC

Covered

Invokamet (canagliflozin/metformin)

Tier 2;3 (ST)

Tier 2;3

NC

Covered

Invokamet XR (canagliflozin/metformin extended release)

Tier 2;3 (ST)

Tier 2;3

NC

PA

Xigduo XR (dapagliflozin/metformin extended release)

NC

Tier 3;4

NC

Tier 3

Covered

Synjardy (empagliflozin/metformin)

Tier 2;3 (ST)

Tier 2;3

Tier 2

Tier 3

PA

Synjardy XR (empagliflozin/metformin extended release)

Tier 2;3 (ST)

Tier 2;3

Tier 2

Tier 3

PA

DIABETES RECOMMENDATIONS AND

TIER COVERAGE CHART

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Medications

BCBSMA

HPHC

Tufts

Tufts Medicare

Preferred

MassHealth

Segluromet (ertugliflozin/metformin)

NC

Tier 3;4

NC

PA

pioglitazone/glimepiride

Tier 1;2 (ST)

Tier 1;2

Tier 1

PA

(Tier 2 once approved)

PA

Duetact (pioglitazone/glimepiride)

Tier 2;3;4 (ST)

NC

Tier 3

NC

PA

alogliptin/pioglitazone

NC

Tier 1

NC

PA

Oseni (alogliptin/pioglitazone)

NC

PA

Qtern (dapagliflozin/saxagliptin)

NC

Premium Formulary: Tier

3;4:

Value Formulary: Tier

3;4;5

NC

PA

Glyxambi (empagliflozin/linagliptin)

Tier 2;3 (ST)

Tier 3;4:NC

Tier 3

NC

PA

Steglujan (ertugliflozin/sitagliptin)

NC

PA

NC = not covered

* There are no completed clinical trials conducted on cardiovascular or renal outcomes

PA = prior authorization

** Weight loss potency: semaglutide>liraglutide>dulaglutide>exenatide>lixisenatide

ST = step therapy required

(-) = no information provided

REFERENCES:

Tier coverage based on the following:

• BCBS: https://home.bluecrossma.com/medication/med-search

• HPHC: https://www.harvardpilgrim.org/portal/page?_pageid=253,13048065&_dad=portal&_schema=PORTAL NOTE: HPHC has 2 formularies (Premium and Value) with different tier plans

• Tufts: https://tuftshealthplan.com/member/employer-individual-or-family-plans/plans-benefits/pharmacy-benefit/pharmacy-formularies

• TMP: https://www.tuftsmedicarepreferred.org/drug-coverage

• MassHealth: https://masshealthdruglist.ehs.state.ma.us/MHDL/pubdownloadpdfcurrent.do?id=45

The Medical Letter: Drug’s for Type 2 Diabetes, Issue 1584, Volume 61, November 4, 2019.