Limited Use Note(s)

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SEMAGLUTIDE3mg Tab
Reason For Use CodeClinical Criteria
662For the treatment of adult patients with type 2 diabetes when adequate glycemic control is not achieved on the maximum tolerated dose of metformin or where metformin is contraindicated or inappropriate. Semaglutide is not funded in combination with another glucagon like peptide-1 receptor agonist (GLP-1 RA) or dipeptidyl peptidase-4 (DPP-4) inhibitor. Oral semaglutide is not funded in combination with injectable semaglutide. Coverage is only provided for one dosage format. Maximum reimbursed dose: 3mg once daily.
LU Authorization Period: Indefinite.