Interactive Drug Benefit List
DIN/NPN/PIN 02389177 KOMBOGLYZE 2.5 MG * 850 MG ORAL TABLET SAXAGLIPTIN HCL/ METFORMIN HCL
680000 HORMONES AND SYNTHETIC SUBSTITUTES
682000 ANTIDIABETIC AGENTS
682005 DIPEPTIDYL PEPTIDASE IV (DPP-4) INHIBITORS
Date Listed/Coverage Update: 01-Apr-2017
Unit Price: 1.3335
LCA Price: N/A
MAC Price:

N/A

Unit of Issue: Tablet
Manufacturer: ASTRAZENECA CANADA INC. (AZC)
ATC: A10BD10
1
Interchangeable Products: No

Coverage Status: STEP THERAPY/ SPECIAL AUTHORIZATION
Applies to Clients of: Non-Group Coverage (Group 1)
Coverage for Seniors (Group 66)
Palliative Coverage (Group 20514, Please note your client may have Group 1 or Group 66 coverage)
Child and Family Services (Group 20403)
Alberta Child Health Benefit (Group 20400)
Children and Youth Services (Group 19824)
Income Support (Group 19823)
Alberta Human Services (AISH) (Group 19823)
Alberta Adult Health Benefit (AAHB) (Group 23609)

Special Authorization Request Form:

DPP-4/SGLT2 Inhibitors/GLP-1 Receptor Agonists Special Authorization Request Form (ABC 60012)

STEP THERAPY

The drug product(s) listed below are eligible for coverage via the step therapy/special authorization process.

FIRST-LINE DRUG PRODUCT(S): METFORMIN
SECOND-LINE DRUG PRODUCT(S): SULFONYLUREAS
AND WHERE INSULIN IS NOT AN OPTION

As add-on therapy for the treatment of Type 2 diabetes in patients with intolerance to and/or inadequate glycemic control on:
- a sufficient trial (i.e. a minimum of 6 months) of metformin, AND
- a sulfonylurea, AND
- for whom insulin is not an option.

Or, for whom these products are contraindicated.

Special authorization may be granted for 24 months.

Note: If a claim for the Step therapy drug product is rejected, pharmacists can use their professional judgment to determine the appropriateness of using the intervention code(s) noted below to re-submit a claim. The pharmacist is responsible to document on the patient's record the rationale for using the second-line therapy drug.

UP - First-line therapy ineffective
UQ - First-line therapy not tolerated
CA - Prior adverse reaction
CB - Previous treatment failure
CJ - Product is not effective

All requests for saxagliptin+metformin must be completed using the DPP-4/SGLT2 Inhibitors/GLP-1 Receptor Agonist Special Authorization Request Form (ABC 60012).

Review Status / Past Decisions

Indication Reviewing
Body
Submission
Completion
Date
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
CDR
Recommendation
Review
Status
DIABETES MELLITUS (TYPE 2) Common Drug Review 2013/08/30 2017/04/01 Step Therapy/Special Authorization
DIABETES MELLITUS (TYPE 2) Common Drug Review 2013/08/30 2014/06/20 View CDR - List with clinical criteria and/or conditions
Indication DIABETES MELLITUS (TYPE 2)
Reviewing
Body
Common Drug Review
Submission
Completion
Date
2013/08/30
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2017/04/01
CDR
Recommendation
Review
Status
Step Therapy/Special Authorization
Indication DIABETES MELLITUS (TYPE 2)
Reviewing
Body
Common Drug Review
Submission
Completion
Date
2013/08/30
CDR
Recommendation
Date
2014/06/20
Expert Committee
Recommendation
Date
ADBL
Effective
Date
CDR
Recommendation
View
Review
Status
CDR - List with clinical criteria and/or conditions
To return to the printable Drug Benefit List and related publications, click here
Last Updated:
NOTICE:
The DBL, DBS and related publications require knowledgeable interpretation and are intended primarily for professional health care practitioners, pharmacies, hospitals and organizations associated with the manufacture, distribution and use of pharmaceutical preparations.
Electronic versions of all DBL and DBS related publications are unofficial versions and are provided for convenience and private use only. Official paper versions can be obtained from Alberta Blue Cross who publishes them on behalf of Alberta Health and Alberta Human Services.
Alberta Health reserves the right to make changes, without notice, to the List through the Interactive DBL(iDBL), and any such changes to the Interactive DBL(iDBL) are effective the date of the change (unless otherwise stated) and regardless of the date of publication in the paper version or updates.