Limited Coverage Drugs - Empagliflozin and empagliflozin-metformin

Generic Name 

empagliflozin empagliflozin-metformin

Strength

10 mg

25 mg

5 mg/500 mg

5 mg/850 mg

5 mg/1000 mg

12.5 mg/500 mg

12.5 mg/850 mg

12.5 mg/1000 mg

Form  tablet tablet

Special Authority Criteria

Approval Period

As part of treatment for type 2 diabetes mellitus:

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

 

Indefinite

 

 

Practitioner Exemptions

  • No practitioner exemptions.

Special Notes

  • Coverage will be provided for either empagliflozin or an eligible thiazolidinedione (TZD)/ dipeptidyl peptidase-4 (DPP-4) inhibitor.
  • For patients that have coverage for a TZD/DPP-4 inhibitor, approval for empagliflozin coverage will result in discontinuation of coverage for the TZD/DPP-4 inhibitor.  
  • 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).

Special Authority Request Form(s)