Diabetes, SGLT-2 Inhibitors
PDL Reference Documents
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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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Carveout ‐ Bill FFS |
Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|---|
| 50458014001 | INVOKANA | canagliflozin | TABLET | 100 mg | N | Y | Pharmacy PA | |
| 50458014030 | INVOKANA | canagliflozin | TABLET | 100 mg | N | Y | Pharmacy PA | |
| 50458014090 | INVOKANA | canagliflozin | TABLET | 100 mg | N | Y | Pharmacy PA | |
| 50458014130 | INVOKANA | canagliflozin | TABLET | 300 mg | N | Y | Pharmacy PA | |
| 50458014190 | INVOKANA | canagliflozin | TABLET | 300 mg | N | Y | Pharmacy PA | |
| 50458094301 | INVOKAMET XR | canagliflozin/metformin HCl | TAB BP 24H | 150 mg-1,000 mg | N | Y | Pharmacy PA | |
| 50458094201 | INVOKAMET XR | canagliflozin/metformin HCl | TAB BP 24H | 150 mg-500 mg | N | Y | Pharmacy PA | |
| 50458094101 | INVOKAMET XR | canagliflozin/metformin HCl | TAB BP 24H | 50 mg-1,000 mg | N | Y | Pharmacy PA | |
| 50458094001 | INVOKAMET XR | canagliflozin/metformin HCl | TAB BP 24H | 50 mg-500 mg | N | Y | Pharmacy PA | |
| 50458054360 | INVOKAMET | canagliflozin/metformin HCl | TABLET | 150 mg-1,000 mg | N | Y | Pharmacy PA | |
| 50458054260 | INVOKAMET | canagliflozin/metformin HCl | TABLET | 150 mg-500 mg | N | Y | Pharmacy PA | |
| 50458054160 | INVOKAMET | canagliflozin/metformin HCl | TABLET | 50 mg-1,000 mg | N | Y | Pharmacy PA | |
| 50458054060 | INVOKAMET | canagliflozin/metformin HCl | TABLET | 50 mg-500 mg | N | Y | Pharmacy PA | |
| 00480352856 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 10 mg | Y | |||
| 00781599031 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 10 mg | Y | Y | ||
| 27241015201 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 10 mg | Y | Y | ||
| 33342058607 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 10 mg | Y | Y | ||
| 33342058610 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 10 mg | Y | Y | ||
| 59651016030 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 10 mg | Y | Y | ||
| 60505491203 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 10 mg | Y | Y | ||
| 62332039330 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 10 mg | Y | Y | ||
| 66993045730 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 10 mg | Y | Y | ||
| 67877060930 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 10 mg | Y | Y | ||
| 67877060990 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 10 mg | Y | Y | ||
| 69097038902 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 10 mg | Y | Y | ||
| 70710138103 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 10 mg | Y | Y | ||
| 70748010606 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 10 mg | Y | Y | ||
| 71921042133 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 10 mg | Y | Y | ||
| 72205043301 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 10 mg | Y | Y | ||
| 72205043303 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 10 mg | Y | Y | ||
| 00310621030 | FARXIGA | dapagliflozin | TABLET | 10 mg | Y | Y | ||
| 00310621039 | FARXIGA | dapagliflozin | TABLET | 10 mg | Y | Y | ||
| 00310621090 | FARXIGA | dapagliflozin | TABLET | 10 mg | Y | Y | ||
| 00310621095 | FARXIGA | dapagliflozin | TABLET | 10 mg | Y | Y | ||
| 00480352756 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 5 mg | Y | |||
| 00781598531 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 5 mg | Y | Y | ||
| 27241015101 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 5 mg | Y | Y | ||
| 33342058507 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 5 mg | Y | Y | ||
| 33342058510 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 5 mg | Y | Y | ||
| 59651015930 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 5 mg | Y | Y | ||
| 60505491103 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 5 mg | Y | Y | ||
| 62332039230 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 5 mg | Y | Y | ||
| 66993045630 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 5 mg | Y | Y | ||
| 67877060830 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 5 mg | Y | Y | ||
| 67877060890 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 5 mg | Y | Y | ||
| 69097038802 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 5 mg | Y | Y | ||
| 70710138003 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 5 mg | Y | Y | ||
| 70748010506 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 5 mg | Y | Y | ||
| 71921042033 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 5 mg | Y | Y | ||
| 72205043201 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 5 mg | Y | Y | ||
| 72205043203 | DAPAGLIFLOZIN | dapagliflozin | TABLET | 5 mg | Y | Y | ||
| 00310620530 | FARXIGA | dapagliflozin | TABLET | 5 mg | Y | Y | ||
| 00310620590 | FARXIGA | dapagliflozin | TABLET | 5 mg | Y | Y | ||
| 00310620595 | FARXIGA | dapagliflozin | TABLET | 5 mg | Y | Y | ||
| 33342040907 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 10 mg-1,000 mg | N | Y | Pharmacy PA | |
| 59651015730 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 10 mg-1,000 mg | N | Y | Pharmacy PA | |
| 63304002830 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 10 mg-1,000 mg | N | Y | Pharmacy PA | |
| 66993036230 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 10 mg-1,000 mg | N | Y | Pharmacy PA | |
| 67877062230 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 10 mg-1,000 mg | N | Y | Pharmacy PA | |
| 70748010406 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 10 mg-1,000 mg | Y | |||
| 72205043701 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 10 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00310628030 | XIGDUO XR | dapagliflozin/metformin | TAB BP 24H | 10 mg-1,000 mg | N | Y | Pharmacy PA | |
| 33342040707 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 10 mg-500 mg | N | Y | Pharmacy PA | |
| 59651015630 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 10 mg-500 mg | N | Y | Pharmacy PA | |
| 63304002730 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 10 mg-500 mg | N | Y | Pharmacy PA | |
| 67877062130 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 10 mg-500 mg | N | Y | Pharmacy PA | |
| 70748010306 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 10 mg-500 mg | Y | |||
| 72205043601 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 10 mg-500 mg | N | Y | Pharmacy PA | |
| 00310627030 | XIGDUO XR | dapagliflozin/metformin | TAB BP 24H | 10 mg-500 mg | N | Y | Pharmacy PA | |
| 00310622560 | XIGDUO XR | dapagliflozin/metformin | TAB BP 24H | 2.5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 33342040809 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 59651015560 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 63304002662 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 66993036160 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 67877062060 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 70748010207 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 5 mg-1,000 mg | Y | |||
| 72205043503 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00310626060 | XIGDUO XR | dapagliflozin/metformin | TAB BP 24H | 5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 33342040607 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 5 mg-500 mg | N | Y | Pharmacy PA | |
| 59651015430 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 5 mg-500 mg | N | Y | Pharmacy PA | |
| 67877061930 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 5 mg-500 mg | N | Y | Pharmacy PA | |
| 70748010106 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 5 mg-500 mg | Y | |||
| 72205043401 | DAPAGLIFLOZIN-METFORMIN ER | dapagliflozin/metformin | TAB BP 24H | 5 mg-500 mg | N | Y | Pharmacy PA | |
| 00310625030 | XIGDUO XR | dapagliflozin/metformin | TAB BP 24H | 5 mg-500 mg | N | Y | Pharmacy PA | |
| 72205043801 | DAPAGLIFLOZIN-SAXAGLIPTIN | dapagliflozin/saxagliptin HCl | TABLET | 10 mg-5 mg | N | Y | Pharmacy PA | |
| 00597038013 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 10 mg-5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597038022 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 10 mg-5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597038068 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 10 mg-5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597038577 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 12.5 mg-2.5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597038586 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 12.5 mg-2.5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597038588 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 12.5 mg-2.5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597039013 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 25 mg-5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597039031 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 25 mg-5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597039071 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 25 mg-5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597039523 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 5 mg-2.5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597039552 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 5 mg-2.5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597039582 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 5 mg-2.5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597015207 | JARDIANCE | empagliflozin | TABLET | 10 mg | Y | Y | ||
| 00597015230 | JARDIANCE | empagliflozin | TABLET | 10 mg | Y | Y | ||
| 00597015237 | JARDIANCE | empagliflozin | TABLET | 10 mg | Y | Y | ||
| 00597015290 | JARDIANCE | empagliflozin | TABLET | 10 mg | Y | Y | ||
| 00597015307 | JARDIANCE | empagliflozin | TABLET | 25 mg | Y | Y | ||
| 00597015330 | JARDIANCE | empagliflozin | TABLET | 25 mg | Y | Y | ||
| 00597015337 | JARDIANCE | empagliflozin | TABLET | 25 mg | Y | Y | ||
| 00597015390 | JARDIANCE | empagliflozin | TABLET | 25 mg | Y | Y | ||
| 00597018207 | GLYXAMBI | empagliflozin/linagliptin | TABLET | 10 mg-5 mg | N | Y | Pharmacy PA | |
| 00597018230 | GLYXAMBI | empagliflozin/linagliptin | TABLET | 10 mg-5 mg | N | Y | Pharmacy PA | |
| 00597018239 | GLYXAMBI | empagliflozin/linagliptin | TABLET | 10 mg-5 mg | N | Y | Pharmacy PA | |
| 00597018290 | GLYXAMBI | empagliflozin/linagliptin | TABLET | 10 mg-5 mg | N | Y | Pharmacy PA | |
| 00597016407 | GLYXAMBI | empagliflozin/linagliptin | TABLET | 25 mg-5 mg | N | Y | Pharmacy PA | |
| 00597016430 | GLYXAMBI | empagliflozin/linagliptin | TABLET | 25 mg-5 mg | N | Y | Pharmacy PA | |
| 00597016439 | GLYXAMBI | empagliflozin/linagliptin | TABLET | 25 mg-5 mg | N | Y | Pharmacy PA | |
| 00597016490 | GLYXAMBI | empagliflozin/linagliptin | TABLET | 25 mg-5 mg | N | Y | Pharmacy PA | |
| 00597028036 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 10 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597028073 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 10 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597028090 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 10 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597030020 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 12.5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597030045 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 12.5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597030093 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 12.5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597029561 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 25 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597029578 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 25 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597029588 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 25 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597029020 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597029059 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597029074 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597016818 | SYNJARDY | empagliflozin/metformin HCl | TABLET | 12.5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597016860 | SYNJARDY | empagliflozin/metformin HCl | TABLET | 12.5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597018018 | SYNJARDY | empagliflozin/metformin HCl | TABLET | 12.5 mg-500 mg | N | Y | Pharmacy PA | |
| 00597018060 | SYNJARDY | empagliflozin/metformin HCl | TABLET | 12.5 mg-500 mg | N | Y | Pharmacy PA | |
| 00597018066 | SYNJARDY | empagliflozin/metformin HCl | TABLET | 12.5 mg-500 mg | N | Y | Pharmacy PA | |
| 00597017518 | SYNJARDY | empagliflozin/metformin HCl | TABLET | 5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597017560 | SYNJARDY | empagliflozin/metformin HCl | TABLET | 5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00597015918 | SYNJARDY | empagliflozin/metformin HCl | TABLET | 5 mg-500 mg | N | Y | Pharmacy PA | |
| 00597015960 | SYNJARDY | empagliflozin/metformin HCl | TABLET | 5 mg-500 mg | N | Y | Pharmacy PA | |
| 00006536403 | STEGLATRO | ertugliflozin pidolate | TABLET | 15 mg | N | Y | Pharmacy PA | |
| 00006536406 | STEGLATRO | ertugliflozin pidolate | TABLET | 15 mg | N | Y | Pharmacy PA | |
| 00006536303 | STEGLATRO | ertugliflozin pidolate | TABLET | 5 mg | N | Y | Pharmacy PA | |
| 00006536306 | STEGLATRO | ertugliflozin pidolate | TABLET | 5 mg | N | Y | Pharmacy PA | |
| 00006537303 | SEGLUROMET | ertugliflozin/metformin | TABLET | 2.5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00006537306 | SEGLUROMET | ertugliflozin/metformin | TABLET | 2.5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00006536903 | SEGLUROMET | ertugliflozin/metformin | TABLET | 2.5 mg-500 mg | N | Y | Pharmacy PA | |
| 00006536906 | SEGLUROMET | ertugliflozin/metformin | TABLET | 2.5 mg-500 mg | N | Y | Pharmacy PA | |
| 00006537403 | SEGLUROMET | ertugliflozin/metformin | TABLET | 7.5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00006537406 | SEGLUROMET | ertugliflozin/metformin | TABLET | 7.5 mg-1,000 mg | N | Y | Pharmacy PA | |
| 00006537003 | SEGLUROMET | ertugliflozin/metformin | TABLET | 7.5 mg-500 mg | N | Y | Pharmacy PA | |
| 00006537006 | SEGLUROMET | ertugliflozin/metformin | TABLET | 7.5 mg-500 mg | N | Y | Pharmacy PA | |
| 00006536803 | STEGLUJAN | ertugliflozin/sitagliptin phos | TABLET | 15 mg-100 mg | N | Y | Pharmacy PA | |
| 00006536806 | STEGLUJAN | ertugliflozin/sitagliptin phos | TABLET | 15 mg-100 mg | N | Y | Pharmacy PA | |
| 00006536703 | STEGLUJAN | ertugliflozin/sitagliptin phos | TABLET | 5 mg-100 mg | N | Y | Pharmacy PA | |
| 00006536706 | STEGLUJAN | ertugliflozin/sitagliptin phos | TABLET | 5 mg-100 mg | N | Y | Pharmacy PA | |
| 70183022130 | INPEFA | sotagliflozin | TABLET | 200 mg | N | Y | Pharmacy PA | |
| 70183022131 | INPEFA | sotagliflozin | TABLET | 200 mg | N | Y | Pharmacy PA | |
| 70183024130 | INPEFA | sotagliflozin | TABLET | 400 mg | N | Y | Pharmacy PA |