Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
sitagliptin plus metformin
Criteria Approval Period

As part of combination treatment of type 2 diabetes mellitus for patients already stabilized on combination treatment with the individual components of metformin and sitagliptin:

WHEN insulin NPH is not an option;

AND AFTER inadequate glycemic control on maximally-tolerated doses of dual therapy of metformin AND a sulfonylurea.

 Indefinite

Practitioner Exemptions
  • None

Special Notes
  1. Due to greater evidence of long-term benefit and enhanced cost-effectiveness, patients should be tried on metformin, sulfonylureas, and insulin NPH (considered and tried if applicable) before considering other agents.
  2. 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 the Special Authority program).
  3. Patients who meet the Limited Coverage criteria for sitagliptin plus metformin automatically receive coverage for pioglitazone.

Special Authority Forms

HL5358 – Pioglitazone/Sitagliptin (PDF 149K)