Limited Coverage Drug – Linagliptin and Linagliptin-metformin

Generic Name / Strength / Form

linagliptin / 5 mg / tablet

linagliptin-metformin / 2.5 mg / 500 mg, 2.5 mg / 850 mg, 2.5 mg / 1000 mg / tablet

Special Authority Criteria

Approval Period

As part of a combination treatment for type 2 diabetes mellitus:

  • When insulin NPH is not an option

AND

  • After inadequate glycemic control on maximum tolerated doses of dual therapy of metformin AND a sulfonylurea.

Indefinte

Practitioner Exemptions

  • None

Special Notes

  1. Based on evidence of long-term benefit and enhanced cost-effectiveness, patients should be tried on metformin, sulfonylureas, and insulin NPH (tried if applicable) before considering other agents.
  2. Patients intolerant to a sulfonylurea may be considered for coverage. Patients intolerant to glyburide may try another sulfonylurea (e.g., gliclazide, which is available through the PharmaCare Special Authority program).
  3. Patients who meet the Limited Coverage criteria for linagliptin automatically receive coverage for pioglitazone and saxagliptin.

Special Authority Request Form(s)