Diabetes, SGLT-2 Inhibitors
PDL Reference Documents
- Diabetes, SGLT-2 Inhibitors - Feb 06, 2025
- Diabetes, SGLT-2 Inhibitors - Oct 05, 2023
- GLP-1 Receptor Agonists and SGLT-2 Inhibitors - Oct 06, 2022
- SGLT-2 Inhibitors Class Update - Aug 05, 2021
- Newer Diabetes Drugs - Aug 06, 2020
- Newer Diabetes Treatments - Jul 26, 2018
- Diabetes Class Update - Sep 28, 2017
- Newer Diabetes Medications and Combinations - Sep 29, 2016
- Sodium-glucose Cotransporter 2 (SGLT2) Inhibitors - Mar 31, 2016
- Diabetes mellitus - Sep 24, 2015
Newsletters
- July 2023 - Update on the Use of SGLT-2 Inhibitors
- September 2020 - Cardiovascular Outcomes Associated with Newer Therapy Classes for Type 2 Diabetes Mellitus
- January 2019 - 2017-18 Year in Review: Important Safety Updates
- November 2017 - Marketing Claims of Newer Drugs and the Evidence
- March 2016 - Antidiabetic Treatments and Cardiovascular Implications
- February 2016 - 2015 in Review: Relevant Safety Updates and Ongoing Safety Concerns
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 | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 50458014001 | INVOKANA | canagliflozin | TABLET | 100 mg | N | Y | PA Document |
| 50458014030 | INVOKANA | canagliflozin | TABLET | 100 mg | N | Y | PA Document |
| 50458014090 | INVOKANA | canagliflozin | TABLET | 100 mg | N | Y | PA Document |
| 50458014130 | INVOKANA | canagliflozin | TABLET | 300 mg | N | Y | PA Document |
| 50458014190 | INVOKANA | canagliflozin | TABLET | 300 mg | N | Y | PA Document |
| 50458094301 | INVOKAMET XR | canagliflozin/metformin HCl | TAB BP 24H | 150 mg-1,000 mg | N | Y | PA Document |
| 50458094201 | INVOKAMET XR | canagliflozin/metformin HCl | TAB BP 24H | 150 mg-500 mg | N | Y | PA Document |
| 50458094101 | INVOKAMET XR | canagliflozin/metformin HCl | TAB BP 24H | 50 mg-1,000 mg | N | Y | PA Document |
| 50458094001 | INVOKAMET XR | canagliflozin/metformin HCl | TAB BP 24H | 50 mg-500 mg | N | Y | PA Document |
| 50458054360 | INVOKAMET | canagliflozin/metformin HCl | TABLET | 150 mg-1,000 mg | N | Y | PA Document |
| 50458054260 | INVOKAMET | canagliflozin/metformin HCl | TABLET | 150 mg-500 mg | N | Y | PA Document |
| 50458054160 | INVOKAMET | canagliflozin/metformin HCl | TABLET | 50 mg-1,000 mg | N | Y | PA Document |
| 50458054060 | INVOKAMET | canagliflozin/metformin HCl | TABLET | 50 mg-500 mg | N | Y | PA Document |
| 66993036230 | DAPAGLIFLOZIN-METFORMIN ER | dapaglifloz propaned/metformin | TAB BP 24H | 10 mg-1,000 mg | N | Y | PA Document |
| 00310628030 | XIGDUO XR | dapaglifloz propaned/metformin | TAB BP 24H | 10 mg-1,000 mg | N | Y | PA Document |
| 00310627030 | XIGDUO XR | dapaglifloz propaned/metformin | TAB BP 24H | 10 mg-500 mg | N | Y | PA Document |
| 00310622560 | XIGDUO XR | dapaglifloz propaned/metformin | TAB BP 24H | 2.5 mg-1,000 mg | N | Y | PA Document |
| 66993036160 | DAPAGLIFLOZIN-METFORMIN ER | dapaglifloz propaned/metformin | TAB BP 24H | 5 mg-1,000 mg | N | Y | PA Document |
| 00310626060 | XIGDUO XR | dapaglifloz propaned/metformin | TAB BP 24H | 5 mg-1,000 mg | N | Y | PA Document |
| 00310625030 | XIGDUO XR | dapaglifloz propaned/metformin | TAB BP 24H | 5 mg-500 mg | N | Y | PA Document |
| 66993045730 | DAPAGLIFLOZIN | dapagliflozin propanediol | TABLET | 10 mg | Y | Y | |
| 00310621030 | FARXIGA | dapagliflozin propanediol | TABLET | 10 mg | Y | Y | |
| 00310621039 | FARXIGA | dapagliflozin propanediol | TABLET | 10 mg | Y | Y | |
| 00310621090 | FARXIGA | dapagliflozin propanediol | TABLET | 10 mg | Y | Y | |
| 00310621095 | FARXIGA | dapagliflozin propanediol | TABLET | 10 mg | Y | Y | |
| 66993045630 | DAPAGLIFLOZIN | dapagliflozin propanediol | TABLET | 5 mg | Y | Y | |
| 00310620530 | FARXIGA | dapagliflozin propanediol | TABLET | 5 mg | Y | Y | |
| 00310620590 | FARXIGA | dapagliflozin propanediol | TABLET | 5 mg | Y | Y | |
| 00310620595 | FARXIGA | dapagliflozin propanediol | TABLET | 5 mg | Y | Y | |
| 00310678030 | QTERN | dapagliflozin/saxagliptin HCl | TABLET | 10 mg-5 mg | N | Y | PA Document |
| 00310677030 | QTERN | dapagliflozin/saxagliptin HCl | TABLET | 5 mg-5 mg | N | Y | PA Document |
| 00597038013 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 10 mg-5 mg-1,000 mg | N | Y | PA Document |
| 00597038022 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 10 mg-5 mg-1,000 mg | N | Y | PA Document |
| 00597038068 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 10 mg-5 mg-1,000 mg | N | Y | PA Document |
| 00597038577 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 12.5 mg-2.5 mg-1,000 mg | N | Y | PA Document |
| 00597038586 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 12.5 mg-2.5 mg-1,000 mg | N | Y | PA Document |
| 00597038588 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 12.5 mg-2.5 mg-1,000 mg | N | Y | PA Document |
| 00597039013 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 25 mg-5 mg-1,000 mg | N | Y | PA Document |
| 00597039031 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 25 mg-5 mg-1,000 mg | N | Y | PA Document |
| 00597039071 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 25 mg-5 mg-1,000 mg | N | Y | PA Document |
| 00597039523 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 5 mg-2.5 mg-1,000 mg | N | Y | PA Document |
| 00597039552 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 5 mg-2.5 mg-1,000 mg | N | Y | PA Document |
| 00597039582 | TRIJARDY XR | empaglifloz/linaglip/metformin | TAB BP 24H | 5 mg-2.5 mg-1,000 mg | N | Y | PA Document |
| 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 | PA Document |
| 00597018230 | GLYXAMBI | empagliflozin/linagliptin | TABLET | 10 mg-5 mg | N | Y | PA Document |
| 00597018239 | GLYXAMBI | empagliflozin/linagliptin | TABLET | 10 mg-5 mg | N | Y | PA Document |
| 00597018290 | GLYXAMBI | empagliflozin/linagliptin | TABLET | 10 mg-5 mg | N | Y | PA Document |
| 00597016407 | GLYXAMBI | empagliflozin/linagliptin | TABLET | 25 mg-5 mg | N | Y | PA Document |
| 00597016430 | GLYXAMBI | empagliflozin/linagliptin | TABLET | 25 mg-5 mg | N | Y | PA Document |
| 00597016439 | GLYXAMBI | empagliflozin/linagliptin | TABLET | 25 mg-5 mg | N | Y | PA Document |
| 00597016490 | GLYXAMBI | empagliflozin/linagliptin | TABLET | 25 mg-5 mg | N | Y | PA Document |
| 00597028036 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 10 mg-1,000 mg | N | Y | PA Document |
| 00597028073 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 10 mg-1,000 mg | N | Y | PA Document |
| 00597028090 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 10 mg-1,000 mg | N | Y | PA Document |
| 00597030020 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 12.5 mg-1,000 mg | N | Y | PA Document |
| 00597030045 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 12.5 mg-1,000 mg | N | Y | PA Document |
| 00597030093 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 12.5 mg-1,000 mg | N | Y | PA Document |
| 00597029561 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 25 mg-1,000 mg | N | Y | PA Document |
| 00597029578 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 25 mg-1,000 mg | N | Y | PA Document |
| 00597029588 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 25 mg-1,000 mg | N | Y | PA Document |
| 00597029020 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 5 mg-1,000 mg | N | Y | PA Document |
| 00597029059 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 5 mg-1,000 mg | N | Y | PA Document |
| 00597029074 | SYNJARDY XR | empagliflozin/metformin HCl | TAB BP 24H | 5 mg-1,000 mg | N | Y | PA Document |
| 00597016818 | SYNJARDY | empagliflozin/metformin HCl | TABLET | 12.5 mg-1,000 mg | N | Y | PA Document |
| 00597016860 | SYNJARDY | empagliflozin/metformin HCl | TABLET | 12.5 mg-1,000 mg | N | Y | PA Document |
| 00597018018 | SYNJARDY | empagliflozin/metformin HCl | TABLET | 12.5 mg-500 mg | N | Y | PA Document |
| 00597018060 | SYNJARDY | empagliflozin/metformin HCl | TABLET | 12.5 mg-500 mg | N | Y | PA Document |
| 00597018066 | SYNJARDY | empagliflozin/metformin HCl | TABLET | 12.5 mg-500 mg | N | Y | PA Document |
| 00597017518 | SYNJARDY | empagliflozin/metformin HCl | TABLET | 5 mg-1,000 mg | N | Y | PA Document |
| 00597017560 | SYNJARDY | empagliflozin/metformin HCl | TABLET | 5 mg-1,000 mg | N | Y | PA Document |
| 00597015918 | SYNJARDY | empagliflozin/metformin HCl | TABLET | 5 mg-500 mg | N | Y | PA Document |
| 00597015960 | SYNJARDY | empagliflozin/metformin HCl | TABLET | 5 mg-500 mg | N | Y | PA Document |
| 00006536403 | STEGLATRO | ertugliflozin pidolate | TABLET | 15 mg | N | Y | PA Document |
| 00006536406 | STEGLATRO | ertugliflozin pidolate | TABLET | 15 mg | N | Y | PA Document |
| 00006536303 | STEGLATRO | ertugliflozin pidolate | TABLET | 5 mg | N | Y | PA Document |
| 00006536306 | STEGLATRO | ertugliflozin pidolate | TABLET | 5 mg | N | Y | PA Document |
| 00006537303 | SEGLUROMET | ertugliflozin/metformin | TABLET | 2.5 mg-1,000 mg | N | Y | PA Document |
| 00006537306 | SEGLUROMET | ertugliflozin/metformin | TABLET | 2.5 mg-1,000 mg | N | Y | PA Document |
| 00006536903 | SEGLUROMET | ertugliflozin/metformin | TABLET | 2.5 mg-500 mg | N | Y | PA Document |
| 00006536906 | SEGLUROMET | ertugliflozin/metformin | TABLET | 2.5 mg-500 mg | N | Y | PA Document |
| 00006537403 | SEGLUROMET | ertugliflozin/metformin | TABLET | 7.5 mg-1,000 mg | N | Y | PA Document |
| 00006537406 | SEGLUROMET | ertugliflozin/metformin | TABLET | 7.5 mg-1,000 mg | N | Y | PA Document |
| 00006537003 | SEGLUROMET | ertugliflozin/metformin | TABLET | 7.5 mg-500 mg | N | Y | PA Document |
| 00006537006 | SEGLUROMET | ertugliflozin/metformin | TABLET | 7.5 mg-500 mg | N | Y | PA Document |
| 00006536803 | STEGLUJAN | ertugliflozin/sitagliptin phos | TABLET | 15 mg-100 mg | N | Y | PA Document |
| 00006536806 | STEGLUJAN | ertugliflozin/sitagliptin phos | TABLET | 15 mg-100 mg | N | Y | PA Document |
| 00006536703 | STEGLUJAN | ertugliflozin/sitagliptin phos | TABLET | 5 mg-100 mg | N | Y | PA Document |
| 00006536706 | STEGLUJAN | ertugliflozin/sitagliptin phos | TABLET | 5 mg-100 mg | N | Y | PA Document |
| 70183022130 | INPEFA | sotagliflozin | TABLET | 200 mg | N | Y | PA Document |
| 70183022131 | INPEFA | sotagliflozin | TABLET | 200 mg | N | Y | PA Document |
| 70183024130 | INPEFA | sotagliflozin | TABLET | 400 mg | N | Y | PA Document |