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:

  • After inadequate glycemic control on maximum tolerated doses of dual therapy of metformin AND a sulfonylurea.

Practitioner Exemptions

  • None

Special Notes

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

Special Authority Request Form(s)