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 or dual therapy of metformin and an insulin.

Indefinite

Practitioner Exemptions

  • None

Special Notes

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