Limited coverage drugs – semaglutide

Generic name		semaglutide
Strength		0.68 mg/mL, 1.34 mg/mL
Form		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 metformin	Indefinite

Practitioner exemptions

• None

Special notes

1. A minimum 3-month trial of metformin should be considered
2. Special Authority coverage of semaglutide is available for up to a maximum dose of 1 mg weekly, in a pen delivery device intended to give a 1 mg dose. The 2 mg dose is currently under review for reimbursement
3. Note: Taking two 0.5 mg doses from a pen delivery device designed to give a 0.5 mg dose is not covered, because the cost is approximately double the cost of a single 1 mg dose in a 1 mg/dose pen
4. Coverage will be provided for either semaglutide or an eligible dipeptidyl peptidase-4 (DPP-4) inhibitor
5. For patients with Special Authority coverage for a DPP-4 inhibitor, approval for semaglutide coverage will result in discontinuation of coverage for the DPP-4 inhibitor 

Special Authority requests

• Log in to eForms
• HLTH 5826 Empagliflozin/Semaglutide for Diabetes (PDF, 747KB)