Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

Actoplus MET pioglitazone-metformin 15-500 mg tablet; 15-850 mg tablet   $$$$ Actoplus Met XR pioglitazone-metformin 15-1,000 mg tablet, ER multiphase 24 hr; 30-1,000 mg tablet, ER multiphase 24 hr   $$$$ Avandamet rosiglitazone-metformin 2-1,000 mg tablet; 4-1,000 mg tablet; 1-500 mg tablet; 2-500 mg tablet; 4-500 mg tablet   Not Applicable Avandaryl rosiglitazone-glimepiride 4-1 mg tablet; 4-2 mg tablet; 4-4 mg tablet; 8-2 mg tablet; 8-4 mg tablet   Not Applicable DUETACT pioglitazone-glimepiride 30-2 mg tablet; 30-4 mg tablet   $$$$ Glucovance glyburide-metformin 2.5-500 mg tablet; 5-500 mg tablet     $$ Janumet sitagliptin-metformin 50-500 mg tablet; 50-1,000 mg tablet   $$$$$ Janumet XR sitagliptin-metformin 100-1000 mg tablet, ER multiphase 24 hr   $$ Janumet XR sitagliptin-metformin 50-1,000 mg tablet, ER multiphase 24 hr   $$ Janumet XR sitagliptin-metformin 50-500 mg tablet, ER multiphase 24 hr   $$ Jentadueto linagliptin-metformin 2.5-1,000 mg tablet; 2.5-850 mg tablet; 2.5-500 mg tablet   $$$ Juvisync sitagliptin-simvastatin 100-10 mg tablet; 100-20 mg tablet; 100-40 mg tablet   $$$$ Kazano alogliptin-metformin 12.5-500 mg tablet; 12.5-1000 mg tablet   Not Applicable Kombiglyze XR saxagliptin-metformin 2.5-1,000 mg tablet, ER multiphase 24 hr   $$$$$ Kombiglyze XR saxagliptin-metformin 5-1,000 mg tablet, ER multiphase 24 hr   $$$$$ Kombiglyze XR saxagliptin-metformin 5-500 mg tablet, ER multiphase 24 hr   $$$$$ Metaglip glipizide-metformin 2.5-250 mg tablet; 2.5-500 mg tablet; 5-500 mg tablet     $$ Oseni alogliptin-pioglitazone 12.5-15 mg tablet; 12.5-30 mg tablet; 12.5-45 mg tablet; 25-15 mg tablet; 25-30 mg tablet;25-45 mg tablet   Not Applicable Prandimet repaglinide-metformin 2-500 mg tablet; 1-500 mg tablet   Not Applicable

Key for Product(s) Listed Above

Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary (Third tier coverage applies for selected plans) Not Reimbursed Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans. Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

© 2002 Managed Markets Insight and Technology, LLC. All Rights Reserved