CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors (dapagliflozin, dapagliflozin/metformin, Steglatro)

Coverage and utilization management for dapagliflozin, dapagliflozin/metformin combination products, and Steglatro (ertugliflozin) including age limits, indications (type 2 diabetes, heart failure, CKD), quantity limits, step therapy and coverage duration for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySodium-Glucose Cotransporter 2 (SGLT2) Inhibitors (dapagliflozin, dapagliflozin/metformin, Steglatro)

Policy CodePolicy N/A

Change TypeReviewed (no material clinical changes)

Effective DateDec 1, 2017

Next Review Date

Key ActionDocument indication, patient age consistent with product, prior adequate/maximized metformin trial (2 g/day) unless using dapagliflozin for heart failure or CKD, and confirm use with standard disease therapy.

POLICY UPDATE CHANGES

Reviewed dates updated through 07/2025 with no stated clinical policy changes.

3Drugs covered (dapagliflozin, dapagliflozin/metformin, Steglatro)

12 moCoverage duration when approved

1/dayTypical quantity limit (dapagliflozin)

Coverage Summary

Scope: Coverage and utilization management for dapagliflozin, dapagliflozin/metformin combination products, and Steglatro (ertugliflozin) for Neighborhood Health Plan of Rhode Island members. Coverage applies for treatment of type 2 diabetes with age-specific limits: Steglatro ≥18 years; dapagliflozin or dapagliflozin/metformin ≥10 years. Dapagliflozin is also covered for treatment of heart failure (NYHA class II–IV) and for patients with chronic kidney disease (CKD) at risk of progression when used in conjunction with standard disease therapy. Effective date: 12/2017. Last review: 07/2025.

Medical Necessity / Coverage Criteria (Initial Therapy)

Medical Necessity / Coverage Criteria

Covered when ALL of the following are met:

ALL of the following

Product and age
- Steglatro age: Patient is 18 years of age or older if requesting Steglatro
- Dapagliflozin age: Patient is 10 years of age or older if requesting dapagliflozin or dapagliflozin/metformin
Indication-specific paths
- Type 2 diabetes prior therapy: Patient has not achieved adequate glucose control using an adequate/maximized dose and appropriate duration of metformin (2 grams/day)2 grams/day
- Heart failure indication: The request is for dapagliflozin used for the treatment of heart failure (NYHA class II-IV)
- CKD indication: The request is for dapagliflozin used in patients with chronic kidney disease (CKD) who are at risk of progression and will be used in conjunction with standard disease therapy

Investigational / Not Covered

Not covered when investigational:

Investigational uses: Any use that is investigational: therapies used at a dose or for a condition other than medically accepted indications per standard compendia (AHFS-DI, Micromedex DrugDex, Clinical Pharmacology, Lexi-Drugs) or unsupported by peer-reviewed literature

Provider Actions & Billing Rules

Prior Authorization

Medical necessity documentation required

Provider must document the indication; product-specific age (Steglatro ≥18 years; dapagliflozin or dapagliflozin/metformin ≥10 years); a prior adequate/maximized metformin trial (2 g/day) unless the request is for dapagliflozin for heart failure (NYHA II-IV) or for CKD at risk of progression; and that dapagliflozin for CKD or HF will be used in conjunction with standard disease therapy.

Step Therapy

Step therapy requirement

Step therapy requirement: a paid claim for at least a 30-day supply of formulary metformin or a formulary SGLT2 within the last 365 days is required for coverage.

Billing Rule

Quantity limit

Quantity limits (verbatim from source, text ambiguous regarding Steglatro wording): dapagliflozin — 1 tablet per day; dapagliflozin/metformin 10-1000 mg — 1 tablet per day; Steglatro — 2 tablets per day (source text presents formatting/spacing issues).

Billing Rule

Coverage duration

When approved, coverage duration is 12 months.

Background & Definitions

Background: SGLT2 inhibitors (dapagliflozin, dapagliflozin/metformin, and Steglatro/ertugliflozin) are covered by Neighborhood Health Plan of Rhode Island for indicated uses including type 2 diabetes, and for dapagliflozin specifically for heart failure (NYHA II–IV) and CKD at risk of progression when used with standard therapy. Investigational or non-compendia uses are not covered — therapies used at a dose or for a condition other than medically accepted indications per standard compendia are considered investigational and excluded.

Definitions: Investigational = therapies used at a dose or for a condition other than medically accepted indications as defined in AHFS‑DI, Micromedex DrugDex, Clinical Pharmacology, or Lexi‑Drugs (or unsupported by peer‑reviewed literature). Maximized dose of metformin = 2 grams/day.