Download Diabetes Meds & Insurance: ADA Recs & Coverage by BCBSMA, HPHC, Tufts, TMP, MassHealth and more Study notes Pharmacy in PDF only on Docsity!
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.
o GLP-1RA with proven CVD benefit (dulaglutide, liraglutide, injectable semaglutide) OR
o SGLT2i with proven CVD benefit (canagliflozin, empagliflozin) if adequate eGFR
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 Tier 1 Covered Glucoghage ( metformin) NC NC NC;Tier 3 NC PA metformin ER Tier 1;2 Tier 1;2 Tier 1 Tier 1 Covered Gluophage XR (metformin extended release) NC 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 -
TIER COVERAGE CHART
Medications BCBSMA HPHC Tufts
Tufts Medicare
Preferred MassHealth
metformin extended release (modified) NC NC
PA
(Tier 2;3 once approved)
NC PA
Glumetza (metformin, modified release) NC NC NC NC PA metformin extended release (osmotic) NC Premium Formulary : Tier 1; Value Formulary : Tier 1;2;3;4 (depends on strength)
PA
(Tier 3 once approved)
NC PA
Fortamet (metformin, osmotic release) NC NC NC 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 NC Covered Farxiga (dapagliflozin) NC Tier 3;4 NC Tier 3 Covered Steglatro (ertugliflozin)* NC Tier 3;4 NC NC PA
Glucagon-like Peptide-1 (GLP-1) Receptor Agonists**
A1C reduction: 1-1.5%
Trulicity (dulaglutide) Tier 2;3 (ST) 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 NC NC NC - Victoza (liraglutide) NC Tier 2;3 (ST) Tier 2 Tier 3 PA Bydureon (exenatide extended release) Tier 2;3 (ST) Tier 2;3 (ST) NC Tier 3 Covered Bydureon BCise Tier 2;3 (ST) Tier 2;3 (ST) NC Tier 3 PA Byetta (exenatide) Tier 2;3 (ST) Tier 2;3 (ST) NC Tier 4 Covered (Brand preferred) Adlyxin (lixisenatide) NC Premium Formulary : Tier 3;4 (ST) Value Formulary : NC
NC NC PA
TIER COVERAGE CHART
Medications BCBSMA HPHC Tufts
Tufts Medicare
Preferred MassHealth
glyburide Tier 1;2 Tier 1;2 Tier 1
PA
(Tier 2 once approved) Covered glyburide micronized tablets Tier 1;2 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;2 Tier 1 Tier 1 Covered nateglinide Tier 1;2 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 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 NC PA
Alpha-Glucosidase Inhibitors
A1C reduction: 0.5-1%
acarbose Tier 1;2 Tier 1;2 Tier 1 Tier 1 Covered Precose (acarbose) Tier 2;3 NC Tier 3 NC PA miglitol Tier 1;2 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
TIER COVERAGE CHART
Medications BCBSMA HPHC Tufts
Tufts Medicare
Preferred MassHealth
colesevelam Tier 1;2 Tier 2;3 Tier 2 Tier 3 PA Welchol (colesevelam) NC NC NC NC Covered (Brand preferred) SymlinPen (pramlintide) Tier 2;3 Tier 2;3 Tier 3 Tier 3 PA
Combination Products
metformin/glipizide Tier 1;2 Tier 1;2 Tier 1 Tier 1 Covered metformin/glyburide Tier 1;2 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 NC Tier 1 NC PA Kazano (alogliptin/metformin) NC NC NC 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 NC NC Covered Invokamet (canagliflozin/metformin) Tier 2;3 (ST) Tier 2;3 NC NC Covered Invokamet XR (canagliflozin/metformin extended release) Tier 2;3 (ST) Tier 2;3 NC 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
