Quick Reference Drug List Diabetes

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