DIABETES RECOMMENDATIONS AND TIER COVERAGE CHART

DIABETES RECOMMENDATIONS AND TIER COVERAGE CHART

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

metformin Glucoghage (metformin) metformin ER Gluophage XR (metformin extended release) metformin solution Riomet solution Riomet ER solution

BCBSMA

Tier 1 NC

Tier 1;2 NC -

HPHC Biguanides A1C reduction: 1-1.5%

Tier 1;2 NC

Tier 1;2 NC

Tier 1;2

Tier 2;3;4

Tier 3;4

-

Tier 3;4

Tufts

Tier 1 NC;Tier 3

Tier 1 NC;Tier 3

Tier 3; (-)

-

Tufts Medicare Preferred

MassHealth

Tier 1 NC

Tier 1 NC -

Tier 3

NC

Covered PA

Covered PA PA

PA > 13 years (Brand preferred)

-

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4/2020

Medications

metformin extended release (modified) Glumetza (metformin, modified release)

metformin extended release (osmotic)

Fortamet (metformin, osmotic release)

Jardiance (empagliflozin) Invokana (canagliflozin) Farxiga (dapagliflozin) Steglatro (ertugliflozin)*

Trulicity (dulaglutide) Ozempic (semaglutide) Rybelsus (oral semaglutide) Victoza (liraglutide) Bydureon (exenatide extended release) Bydureon BCise Byetta (exenatide)

Adlyxin (lixisenatide)

DIABETES RECOMMENDATIONS AND TIER COVERAGE CHART

BCBSMA

NC

HPHC

NC

Tufts

PA (Tier 2;3 once approved)

NC

NC

NC

Premium Formulary: Tier

NC

1;2 Value Formulary: Tier 1;2;3;4 (depends on

PA (Tier 3 once approved)

strength)

NC

NC

NC

Sodium-glucose co-transporter 2 Inhibitors (SGLT2) A1C reduction: 0.5-1%

Tier 2;3 (ST)

Tier 2;3

Tier 2

Tier 2;3 (ST)

Tier 2;3

NC

NC

Tier 3;4

NC

NC

Tier 3;4

NC

Glucagon-like Peptide-1 (GLP-1) Receptor Agonists** A1C reduction: 1-1.5%

Tier 2;3 (ST)

Tier 2;3 (ST)

Tier 2

NC

Tier 2;3 (ST)

Tier 2

NC

NC

NC

NC

Tier 2;3 (ST)

Tier 2

Tier 2;3 (ST)

Tier 2;3 (ST)

NC

Tier 2;3 (ST)

Tier 2;3 (ST)

NC

Tier 2;3 (ST)

Tier 2;3 (ST)

NC

Premium Formulary: Tier

NC

3;4 (ST)

NC

Value Formulary: NC

2 of 6

Tufts Medicare Preferred

NC NC

NC

NC

Tier 3 NC

Tier 3 NC

Tier 3 Tier 3

NC Tier 3 Tier 3 Tier 3 Tier 4

NC

MassHealth

PA PA

PA

PA

Covered Covered Covered

PA

PA PA PA Covered PA Covered (Brand preferred) PA

4/2020

Medications

Xultophy (insulin degludec/liraglutide)

Soliqua (insulin glargine/lixisenatide)

Januvia (sitagliptin) Tradjenta (linagliptin) alogliptin Nesina (alogliptin) Onglyza (saxagliptin)

glimepiride Amaryl (glimepiride) glipizide Glucotrol (glipizide) glipizide ER/XL extended release Glucotrol XL (glipizide extended release)

DIABETES RECOMMENDATIONS AND TIER COVERAGE CHART

BCBSMA

HPHC

Tufts

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

A1C reduction: 0.5-1% versus insulin alone

NC

PA (Tier 3;4 once approved)

NC

Premium Formulary: PA

NC

(Tier 3;4 once approved)

Value Formulary: NC

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors A1C reduction: 0.5-1%

Tier 2;3 (ST)

Tier 2;3

NC

Tier 2;3

Premium Formulary: NC

NC

Value Formulary:

Tier 3;4;5 (ST)

NC

NC

Tier 2;3 (ST)

NC

Sulfonylureas A1C reduction: 1-1.5%

Tier 1

Tier 1;2

Tier 2;3;4 Tier 1

Tier 2;3;4 Tier 1;2 Tier 2;3;4

NC Tier 1

NC Tier 1;2

NC

NC

Tier 2 NC

Tier 1 NC NC

Tier 1 Tier 3 Tier 1 Tier 3 Tier 1 Tier 3

Tufts Medicare Preferred

MassHealth

NC

PA

NC

PA

Tier 3 Tier 3

NC

NC NC

Covered Covered

PA

PA Covered

PA (Tier 1 once approved)

NC Tier 1

NC Tier 1

NC

Covered

PA Covered

PA Covered

PA

3 of 6

4/2020

glyburide

Medications

glyburide micronized tablets Glynase Prestab (glyburide micronized tablets)

repaglinide nateglinide Starlix (nateglinide)

pioglitazone Actos (pioglitazone) Avandia (rosiglitazone)

acarbose Precose (acarbose) miglitol Glyset (miglitol)

Cycloset (bromocriptine)

DIABETES RECOMMENDATIONS AND TIER COVERAGE CHART

BCBSMA

Tier 1;2

HPHC

Tier 1;2

Tier 1;2

Tier 1;2

Tier 2;3;4

NC

Meglitinides

A1C reduction: 0.5-1%

Tier 1;2

Tier 1;2

Tier 1;2

Tier 1;2

Tier 2;3;4

NC

Thiazolidinediones A1C reduction: 1-1.5%

Tier 1;2 (ST)

Tier 1;2

Tier 2;3;4 (ST)

NC

Tier 2;3;4; (ST)

Tier 3;4

Alpha-Glucosidase Inhibitors A1C reduction: 0.5-1%

Tier 1;2

Tier 1;2

Tier 2;3

NC

Tier 1;2

Tier 1;2

Tier 2;3;4

NC

Miscellaneous A1C reduction: 0.5%

Tier 2;3;4

Tier 2;3

4 of 6

Tufts

Tier 1 Tier 1 Tier 3

Tier 1 Tier 1 Tier 3

Tier 1 Tier 3

NC

Tier 1 Tier 3 Tier 2 Tier 3

Tier 2

Tufts Medicare Preferred

PA (Tier 2 once approved)

PA (Tier 1 once approved)

NC

MassHealth

Covered

Covered PA

Tier 1 Tier 3

NC

Covered Covered

PA

Tier 1 NC NC

Tier 1 NC

Tier 3 NC

Tier 3

Covered PA PA

Covered PA

Covered PA

PA

4/2020

DIABETES RECOMMENDATIONS AND TIER COVERAGE CHART

colesevelam

Medications

Welchol (colesevelam) SymlinPen (pramlintide)

metformin/glipizide

metformin/glyburide

metformin/repaglinide pioglitazone/metformin Actoplus Met (pioglitazone/metformin) Actoplus Met XR (pioglitazone/metformin extended release) alogliptin/metformin Kazano (alogliptin/metformin) Janumet (sitagliptin/metformin) Janumet XR (sitagliptin/metformin extended release) Jentadueto (linagliptin/metformin) Jentadueto XR (linagliptin/metformin extended release) Kombiglyze XR (saxagliptin/metformin extended release) Invokamet (canagliflozin/metformin) Invokamet XR (canagliflozin/metformin extended release) Xigduo XR (dapagliflozin/metformin extended release) Synjardy (empagliflozin/metformin) Synjardy XR (empagliflozin/metformin extended release)

BCBSMA

Tier 1;2

HPHC

Tier 2;3

NC

NC

Tier 2;3 Tier 1;2

Tier 2;3

Combination Products

Tier 1;2

Tier 1;2

Tier 1;2

Tier 1;2 Tier 1;2 (ST) Tier 2;3;4 (ST)

NC Tier 1;2

NC

Tier 2;3;4 (ST)

NC

NC NC Tier 2;3 (ST) Tier 2;3 (ST) NC NC Tier 2;3 (ST) Tier 2;3 (ST) Tier 2;3 (ST) NC Tier 2;3 (ST) Tier 2;3 (ST)

NC NC Tier 2;3 Tier 2;3 Tier 2;3 Tier 2;3 NC Tier 2;3 Tier 2;3 Tier 3;4 Tier 2;3 Tier 2;3

5 of 6

Tufts

Tier 2

NC

Tier 3

Tier 1

Tier 1

Tier 1 Tier 1 Tier 3

Tier 3

Tier 1 NC

Tier 2 Tier 2

NC NC NC NC NC NC Tier 2 Tier 2

Tufts Medicare Preferred

Tier 3

NC Tier 3

MassHealth

PA

Covered (Brand preferred)

PA

Tier 1 PA

(Tier 2 once approved) NC

Tier 3 NC

NC

NC NC Tier 3 Tier 3 Tier 3 Tier 3 NC NC NC Tier 3 Tier 3 Tier 3

Covered

Covered

PA PA PA

PA

PA PA Covered Covered Covered PA Covered Covered PA Covered PA PA

4/2020

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