Limited Coverage Drugs - dapagliflozin

Generic Name

dapagliflozin

Strength

10 mg

Form

tablet

Special Authority Criteria

Approval Period

For the treatment of heart failure (HF) with reduced ejection fraction (HFrEF) in adult patients with New York Heart Association (NYHA) class II or III HF if all the following clinical criteria are met:

  • Reduced left ventricular ejection fraction (LVEF) (<= 40%)

AND

  • As adjunctive therapy (used in combination with a medication from each of the following categories):
    • an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin II receptor antagonist (ARB); AND
    • a beta blocker; AND
    • an aldosterone antagonist

Indefinite

Practitioner Exemptions

  • None

Special Notes

  • None

Special Authority Request Form(s)