Limited coverage criteria – semaglutide

Last updated on March 21, 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 through eForms

Generic name		semaglutide
Strength & form		0.68 mg/mL, 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 metformin	Indefinite

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

A minimum 3-month trial of metformin should be considered
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
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
Coverage will be provided for either semaglutide or an eligible dipeptidyl peptidase-4 (DPP-4) inhibitor
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 request form(s)

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