Diagnosis: Endocrine/Metabolic/Nutritional.
Treatment: Pharmacy/Prescription Drugs.
The insurer denied Janumet.
The denial is overturned.

The patient is a male with a history of diabetes, hypertension, coronary artery disease, and hyperlipidemia. His provider is requesting coverage for non-formulary Janumet. Beside Janumet, he is taking empagliflozin and glimepiride, suggesting that the patient's diabetes is difficult to control. An office visit note documents that the patient's blood control was poor on Jentadueto, along with the empagliflozin and glimepiride, compared to when he previously was on Janumet. Jentadueto was discontinued and Janumet was prescribed again. Subsequent office visit notes document adequate diabetes control on Janumet.

The plan's determination is overturned.

In this patient, the formulary drug Jentadueto/Jentadueto extended release (XR) had been ineffective compared to the non-formulary drug Janumet.
The medical records document that the patient's diabetes control was worse on the formulary drug Jentadueto compared to when he was taking non-formulary Janumet. Both medications are a combination of a Dipeptidyl-peptidase (DPP)-4 inhibitor (linagliptin in Jentadueto, sitagliptin in Janumet) combined with metformin, a biguanide. Although both linagliptin and sitagliptin are classified as DPP-4 inhibitors, they are indeed different drugs, and it is not uncommon for medications in the same class to have different effectiveness or side effects in any given patient. The information provided indicates that there is only one DPP-4/biguanide combination on the formulary, Jentadueto/Jentadueto XR. Therefore, based on the standard of care, and the peer reviewed literature, as well as the plan's non-formulary coverage criteria, the requested drug is more appropriate than the formulary drug in this case.