Diabetes, SGLT-2 Inhibitors
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PDL Status Values
Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the
Non-Preferred Drugs in Select PDL Classes prior authorization criteria.
New drugs will be listed as N until reviewed by the P&T Committee and are subject to the
New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.
To request a Prior Authorization, please use this form.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| dapagliflozin propanediol | DAPAGLIFLOZIN | TABLET | Y | N | ||
| canagliflozin/metformin HCl | INVOKAMET | TABLET | N | Pharmacy PA | N | Jan 29, 2015 |
| dapaglifloz propaned/metformin | DAPAGLIFLOZIN-METFORMIN ER | TAB BP 24H | N | Pharmacy PA | N | |
| dapagliflozin/saxagliptin HCl | QTERN | TABLET | N | Pharmacy PA | N | |
| empagliflozin/linagliptin | GLYXAMBI | TABLET | N | Pharmacy PA | N | |
| empagliflozin/metformin HCl | SYNJARDY XR | TAB BP 24H | N | Pharmacy PA | N | |
| ertugliflozin/metformin | SEGLUROMET | TABLET | N | Pharmacy PA | N | |
| ertugliflozin/sitagliptin phos | STEGLUJAN | TABLET | N | Pharmacy PA | N |