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SGLT2 Inhibitors

DrugSGLT2 Inhibitors

July 2018

Therapeutic Area - Hypoglycemics

Single-entity Products

Preferred Nonpreferred



Fixed Dose Combination Products

Preferred Nonpreferred

Invokamet XR
Xigduo XR
Synjardy XR

Approval criteria for nonpreferred single entity products

  • Patient is 18 years of age or older AND
  • Patient must have a diagnosis of type 2 diabetes mellitus AND
  • Patient has not achieved adequate glycemic control on at least three of the following used separately or simultaneously:
    • metformin (alone or in combination with a sulfonylurea or a thiazolidinedione);
    • a sulfonylurea (alone or in combination with metformin);
    • an oral DPP IV inhibitor (e.g., Januvia, Onglyza)
    • a preferred GLP-1 receptor agonist AND
  • Patient has had an adequate adherent trial and failure of (or contraindication to) at least 2 preferred SGLT2 inhibitors


Patient must not have any one of the following conditions:

  • Estimated glomerular filtration rate (eGFR) < 30mL/min/1.73m2
  • End-stage renal disease (ESRD)
  • Be on dialysis

Approval criteria for nonpreferred fixed dose combination products

  • Patient must meet ALL criteria for nonpreferred single entity products AND
  • Prescriber provides a compelling clinical reason why a fixed dose combination will provide superior efficacy than each component taken separately AND
  • If an extended release (XR) formulation is requested, prescriber provides a compelling clinical reason why the XR formulation will provide better clinical results than non-XR formulation

Quantity limits

  • Single entity products and extended release formulation of fixed dose combination products: 34 tablets per 34 days
  • Fixed dose combination products: 68 tablets per 34 days


MHCP Provider Call Center 651-431-2700 or 800-366-5411

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