Limited Coverage Drugs – Saxagliptin and Saxagliptin-metformin
Generic Name / Strength / Form
saxagliptin / 2.5 mg, 5 mg / tablet
|saxagliptin-metformin / 2.5 mg / 500 mg, 2.5 mg / 850 mg, 2.5 mg / 1000 mg / tablet|
|Special Authority Criteria||Approval Period|
|As part of a combination treatment for type 2 diabetes mellitus:
- Based on evidence of long-term benefit and enhanced cost-effectiveness, patients should be tried on metformin, sulfonylureas, and insulin NPH (if applicable) before considering other agents.
- 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).
- Patients who meet the Limited Coverage criteria for saxagliptin automatically receive coverage for pioglitazone and linagliptin.