Limited coverage criteria – empagliflozin and empagliflozin-metformin

Last updated on April 2, 2025

Special Authority requests can now be submitted online. It's simple and quick!

This drug is eligible for automatic approval when patient meets criteria and the request is submitted by eForms.

Generic name	Strength	Form
empagliflozin	10 mg 25 mg	tablet
empagliflozin-metformin	5 mg/500 mg 5 mg/850 mg 5 mg/1000 mg 12.5 mg/500 mg 12.5 mg/850 mg 12.5 mg/1000 mg	tablet

Special Authority criteria	Approval period
As part of treatment for type 2 diabetes mellitus: After inadequate glycemic control on maximum tolerated dose of metformin	Indefinite

Special Authority criteria

Approval period

As part of treatment for type 2 diabetes mellitus:

After inadequate glycemic control on maximum tolerated dose of metformin

Indefinite

Practitioner exemptions

None

Special notes

A minimum three-month trial of metformin should be considered
Coverage will be provided for either empagliflozin or an eligible dipeptidyl peptidase-4 (DPP-4) inhibitor
For patients that have coverage for DPP-4 inhibitor, approval for empagliflozin coverage will result in discontinuation of coverage for DPP-4 inhibitor

Special Authority request form(s)

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Limited coverage criteria – empagliflozin and empagliflozin-metformin

Generic name

Strength

Form

Special Authority criteria

Approval period

Practitioner exemptions

Special notes

Special Authority request form(s)