Trillium Medicaid Formulary Update: Dapagliflozin and Dapagliflozin-Metformin ER Products
Date: 05/27/26
Effective June 15, 2026, Trillium Medicaid will update formulary coverage for dapagliflozin and dapagliflozin-metformin extended-release products.
Previously, all generic products in this class were covered without prior authorization. With the availability of additional generic products, coverage will be limited to select generic products. All other products, including brand products and non-preferred generics, will be designated as non-formulary.
Because these products are interchangeable, a new prescription is not required for members to receive a preferred product. If you are contacted by a dispensing pharmacy regarding a rejected claim or prior authorization requirement, please ask the pharmacy to confirm that a Trillium-preferred product was selected. The Pharmacy Help Desk can assist with product selection at 1-833-750-4499. Preferred products, NDCs, and applicable quantity limits are listed below. Additional products that become available will be evaluated and may be added as preferred products if cost effective.
| Product | Strength | Quantity Limit | Preferred NDCs |
|---|---|---|---|
| Dapagliflozin | 5 mg | 1 tab per day |
|
| Dapagliflozin | 10 mg | 1 tab per day |
|
| Dapagliflozin + Metformin ER | 5 mg / 500 mg | 2 tabs per day |
|
| Dapagliflozin + Metformin ER | 10 mg / 500 mg | 2 tabs per day |
|
| Dapagliflozin + Metformin ER | 5 mg / 1000 mg | 1 tab per day |
|
| Dapagliflozin + Metformin ER | 10 mg / 1000 mg | 2 tabs per day |
|