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PAxx Januvia/ sitagliptin

U.S. Doctors Resources, L.L.C.



            ®Januvia®/ sitagliptin             Janumet® sitagliptin/ metformin
Actos®/ pioglitazone Avandia®/ rosiglitazone
Glycet®/ miglitol Trulicity®     dulaglutide
Tradjenta®/ linagliptin Invokana®     canagliflozin
Invokamet®/ canagliflozin/ metforminDuetact®     pioglitazone/metformin
Kazano®     alogliptin/ metformin Kombiglyze® xanagliptin/ metformin
Jentdueto®     linagliptin/ metformin Xigduo®     dapagliflozin/ metformin
Onglyza®     rosiglitazone Farxiga®     dapagliflozin
Oseni®     alogliptin/ pioglitazone Nesina®     alogliptin
Symlinpen® pramlintide Gyxambi® empagliflozin/ linagliptin


Non- Insulin Requiring Diabetes Mellitus


The Prior Authorization for this medication has been denied. Further review is pending as:

Metformin 500mg ER is Free of Deductible.
Testosterone cypionate may improve diabetes control.

1. There is no superiority of commercial preparations of any non-insulin for Non- Insulin Requiring Diabetes Mellitus[1] over metformin. Therefore, metformin 1000mg twice daily is initially approved by the Benefit Manager for all with Diabetes Mellitus. The Metformin ER may have less gastro-intestinal related symptoms. Record symptoms initially and at 3-months in non-critical patients.

2. Contact Benefit Manager for Referral for an Alternative Pricing should Metformin not be adequate in lowering glycogenated hemoglobin (HgB A1c) to acceptable range and insulin therapy is refused or not indicated.

3. Contact Benefit Manager for possible Referral should patient be considered for Anabolic Therapy[2] for Diabetes.

Pending (1.), (2.) and (3.), the employee/ dependent may continue the medication as prescribed by the treating physician by attaching a valid 3-month prescription with up to 12-months of refills to the Cover Page and mailing it back to:

ATTN: Benefit Manager
City of Hazel Park Self-Insurance Health Program
111 East Nine Mile Road
Hazel Park, Michigan 48030

Please send the demographics about the patient that appear on the Cover Page of the Prior Authorization form and the Credit Card Information from the Flexible Spending Account in the boxes below.


Demographics Health Insurance/ Credit Card
Member Name:____________________________________ Member Name on the Card:_____________________________________
Insurance ID:____________________________________ Issuing Service: VISA, MC, Discover _________________
Date of Birth:____________________________________ Number:____________________________________
Street Address:____________________________________ Expiration:____________________________________
City/ State/ Zip code:____________________________________CVV Code:____________________________________
Telephone Number:____________________________________
Signature of Employee/ Insured:

Signature of Treating Physician:___________________________________

1. Clin Ther. 2014 Nov 1;36(11):1576-87. doi: 10.1016/j.clinthera.2014.07.019. Epub 2014 Aug 20. Cost-effectiveness of insulin glargine versus sitagliptin in insulin-naïve patients with type 2 diabetes mellitus. Brown ST1, Grima DG2, Sauriol L3.

2. Eur J Endocrinol. 2006 Jun;154(6):899-906. Testosterone replacement therapy improves insulin resistance, glycaemic control, visceral adiposity and hypercholesterolaemia in hypogonadal men with type 2 diabetes.Kapoor D, Goodwin E, Channer KS, Jones TH

Signed b.n.r. Benefit Manager ___________________________________ date:__________

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