Limited Coverage Drugs – semaglutide

Generic Name



1.34 mg/mL


solution for subcutaneous injection

Special Authority Criteria

Approval Period

As part of 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.


Practitioner Exemptions

  • None

Special Notes

  • Coverage will be provided for either semaglutide or an eligible dipeptidyl peptidase-4 (DPP-4) inhibitor.
  • For patients that have coverage for DPP-4 inhibitor, approval for semaglutide coverage will result in discontinuation of coverage for DPP-4 inhibitor.
  • 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).

Special Authority Request Form(s)