Janumet® & Janumet XR® (sitagliptin/metformin), Januvia® (sitagliptin), Jentadueto® (linagliptin/metformin)

Authorization form also may include: 

  • Onglyza® (saxagliptin)
  • Kombiglyze XR® (saxagliptin/metformin)
  • Tradjenta® (linagliptin)

Authorization form

Optimized (07/2020)

Priority Health Medicaid no longer utilizes drug-specific prior authorization forms. Visit the Medicaid Approved Drug List (ADL) to find the new PA form and drug criteria document.

Go to Medicaid ADL