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 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