Limited coverage drugs – empagliflozin and empagliflozin-metformin

Last updated on January 22, 2024

Special Authority requests can now be submitted online. It's simple and quick!

This drug is eligible for automatic approval when patient meets criteria and the request is submitted by eForms.

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 dose of metformin	Indefinite

Special Authority criteria

Approval period

As part of treatment for type 2 diabetes mellitus:

After inadequate glycemic control on maximum tolerated dose of metformin

Indefinite

Practitioner exemptions

None

Special notes

A minimum three-month trial of metformin should be considered
Coverage will be provided for either empagliflozin or an eligible dipeptidyl peptidase-4 (DPP-4) inhibitor
For patients that have coverage for DPP-4 inhibitor, approval for empagliflozin coverage will result in discontinuation of coverage for DPP-4 inhibitor

Special Authority requests

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Limited coverage drugs – empagliflozin and empagliflozin-metformin

Practitioner exemptions

Special notes

Special Authority requests