Limited Coverage Drugs – saxagliptin and saxagliptin-metformin

Generic Name

saxagliptin

saxagliptin-metformin

Strength

  • 2.5 mg
  • 5 mg
  • 2.5 mg/500 mg
  • 2.5 mg/850 mg
  • 2.5 mg/1000 mg

Form

tablet

tablet

Special Authority Criteria

Approval Period

As part of a combination 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

  1. 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).
  2. Patients who meet the Limited Coverage criteria for saxagliptin automatically receive coverage for linagliptin.

Special Authority Request Form(s)