Limited coverage criteria – linagliptin and linagliptin-metformin

 

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Generic name	Strength	Form
linagliptin	5 mg	tablet
linagliptin-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 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 Special Authority)
2. Patients who meet the limited coverage criteria for linagliptin automatically receive coverage for saxagliptin

Special Authority request form(s)

• Log in to eForms
• HLTH 5481 – Third-Line Anti-Diabetic Drugs (PDF, 672KB)