Quick Reference Drug List Diabetes

Quick Reference Drug ListDiabetesUS Script Contact Information: Prior Authorization Phone: 1-866-399-0928Prior Authorization Fax: 1-866-399-0929Clinical Hours:Monday – Friday10:00am – 8:00pm ESTPeach State Contact Information: Provider Inquiry Phone: 1-866-874-0633Key: * = Generic product availableDrugDosage FormMedicaidPDL StatusMedicare AdvantageFormulary StatusRapid-Acting InsulinApidra ® 10mL vials and 3mL pen (Solostar) No Yes – vials only(Insulin Glulisine)Humalog ®Humalog - 10mL vials, 5 × 1.5mLand 5 × 3mL cartridges, andYes-10ml vials only Yes – vials and disposablepens(Insulin Lispro)5 × 3mL disposable pen insulin(not catridges)delivery devices.NovoLog ® 10mL vials, Yes-10ml vials only Yes – vials, Flexpen(Insulin Aspart)3mL PenFill cartridges, and 3mLFlexPen prefilled syringesShort-Acting InsulinHumulin R ® 10mL vials Yes Yes(Insulin Regular)Novolin R ® 10mL vials Yes Yes(Insulin Regular)Humulin N ®(Insulin Isophane)Intermediate-Acting Insulin10mL vials , 5 × 3mL disposable Yes-10ml vials onlypenYesNovolin N ® 10mL vials Yes Yes(Insulin Isophane)Lantus ®(Insulin Glargine)Long-Acting Insulin10mL vials and 3mL cartridgesystem for use with OptiClikYes-10ml vials onlyYes-10ml vials onlyLevemir ®(Insulin Detemir)10mL vials, 3mL FlexPen prefilledsyringesNoYesHumulin 70/30 ®Novolin 70/30 ®Humulin 50/50 ®(Insulin Isophane and Regular)Pre-Mixed Insulin70% isophane insulin (NPH) and30% insulin injection (regular). In5 × 3mL disposable pen insulindelivery devices, and 10mL vials(Novolin – vials only)50% isophane insulin (NPH) and50% insulin injection (regular). In10mL vials.Yes-10ml vials only Yes – except 50/50Last Updated: 11/2011 Page 1 of 4

DrugDosage FormHumalog Mix 50/50 ® Humalog Mix - In 10mL vials and 5× 3mL disposable pen and KwikPenHumalog Mix 75/25 ®insulin delivery devices.MedicaidPDL StatusYes-10ml vials onlyMedicare AdvantageFormulary StatusYes(Insulin Lispro)Novolog Mix 70/30 ®(Insulin Aspart)10mL vials and 3mL FlexPenprefilled syringesYes-10ml vials onlyYesOther InsulinHumulin R Regular U-500 ® 20mL vials No Yes(Concentrated)(Insulin Regular Concentrate)Other Injectable Antidiabetic AgentsByetta ® Injection, solution: 250mcg/mL; No Yes – Requires PA(exenatide) 1.2 and 2.4mL prefilled pen (60doses)Symlin ®Injection, solution: 0.6mg/mL, 5ml NoYes – Requires PAvials(pramlintide acetate)1mg/mL, 1.5 and 2.7mL multidosepen-injectorsVictoza ® Injection, sol: 18mg/3mL pens No No(liraglutide)Alpha-Glucosidase Inhibitorsacarbose* Tablets: 25mg, 50mg, 100mg No Yes(Precose ® )Glyset ® Tablets: 25mg, 50mg, 100mg No Yes(miglitol)BiguanidesRiomet ® Solution; oral: 500mg per 5mL No No(metformin)Glumetza ®(metformin)Fortamet ®(metformin)Tablets: 500mg ER, 1000mg ER(modified release)Tablets: 500mg ER, 1000mg ER(osmotic)metformin* Tablets: 500mg, 850mg, 1000mg Yes Yes(various)metformin ER* Tablets: 500mg ER, 750mg ER Yes Yes(Glucophage ® XR)NoNoNoNoDipeptidyl Peptidase-4 InhibitorJanuvia ® Tablets: 25mg, 50mg, 100mg No Yes(sitagliptin)Onglyza ® Tablets: 2.5mg, 5mg No No(saxagliptin)Last Updated: 11/2011 Page 2 of 4

DrugDosage FormMedicaidPDL StatusMeglitinidesnateglinide* Tablets: 60mg, 120mg No Yes(Starlix ® )Prandin ® Tablets: 0.5mg, 1mg, 2mg No Yes(repaglinide)Sulfonylureaschlorpropamide* Tablets: 100mg, 250mg No Yes(Diabinese ® )glimepiride* Tablets: 1mg, 2mg, 4mg Yes Yes(Amaryl ® )glipizide* Tablets: 5mg, 10mg Yes Yes(Glucotrol ® )glipizide ER* Tablets: 2.5mg, 5mg, 10mg XL Yes Yes(Glucotrol XL ® )glyburide* Tablets: 1.25mg, 2.5mg, 5mg Yes Yes(Micronase ® , Diabeta ® )glyburide, micronized*(Glynase ® )Tablets, micronized: 1.5mg, 3mg,6mgtolazamide* Tablets: 250mg, 500mg No No(generic only)tolbutamide* Tablets: 500mg No Yes(Orinase ® )Thiazolidinediones (TZDs)Actos ® Tablets: 15mg, 30mg, 45mg Yes Yes(pioglitazone)Avandia ® Tablets: 2mg, 4mg, 8mg No Yes(rosiglitazone maleate)YesYesMedicare AdvantageFormulary StatusActoPlus Met ®(pioglitazone/metformin)(pioglitazone/metformin)Avandamet ®(rosiglitazone/metformin)Combination ProductsTablets: pioglitazone15mg/metformin 500mg;15mg/850mgTablets: rosiglitazone2mg/metformin 500 mg;2mg/1000mg; 4mg/500mg;4mg/1000mgJanumet ® Tablets: sitagliptin 50(sitagliptin/metformin)mg/metformin 500 mg;50mg/1000mgDuetact ®(pioglitazone/glimepiride)Avandaryl ®(rosiglitazone/glimepiride)Tablets: pioglitazone30mg/glimepiride 2mg; 30mg/4mgTablets: rosiglitazone4mg/glimepiride 1mg; 4mg/2mg;4mg/4mg; 8mg/2mg; 8mg/4mgYesNoNoNoNoYesYesNoYesYesLast Updated: 11/2011 Page 3 of 4

Drugglipizide/metformin*(Metaglip ® )Dosage FormTablets: glipizide 2.5mg/metformin250 mg; 2.5mg/500mg;5mg/500mgYesMedicaidPDL StatusMedicare AdvantageFormulary StatusYesglyburide/metformin*(Glucovance ® )Tablets: 1.25mg/250 mg;2.5mg/500mg; 5mg/500mgYesYesPrandimet ®(repaglinide/metformin)Tablets: repaglinide1mg/metformin 500mg;2mg/500mgNoNoLast Updated: 11/2011 Page 4 of 4