Are SGLT2 (sodium-glucose cotransporter 2) inhibitors, such as dapagliflozin (Farxiga), empagliflozin (Jardiance), and canagliflozin (Invokana), covered by Medicare for patients with type 2 diabetes?

Medicare Coverage of SGLT2 Inhibitors

Yes, all major SGLT2 inhibitors including dapagliflozin (Farxiga), empagliflozin (Jardiance), and canagliflozin (Invokana) are covered by Medicare, though coverage varies by specific Medicare plan and may require prior authorization.

Medicare Coverage Details for SGLT2 Inhibitors

Medicare coverage for SGLT2 inhibitors is primarily through Medicare Part D prescription drug plans. Coverage specifics depend on:

• Plan formulary: Each Medicare Part D plan has its own formulary (list of covered medications)
• Tier placement: SGLT2 inhibitors are typically placed in higher tiers (Tier 3 or 4), which means higher copayments
• Prior authorization: Many plans require prior authorization to demonstrate medical necessity

Coverage Considerations

1. Medicare Part D: Primary coverage mechanism for outpatient prescription medications
2. Medicare Advantage (Part C): May include prescription drug coverage that includes SGLT2 inhibitors
3. Formulary restrictions: Plans may prefer one SGLT2 inhibitor over others
4. Step therapy: Some plans may require trying other diabetes medications first

Clinical Benefits Supporting Coverage

The American Diabetes Association and American College of Cardiology strongly recommend SGLT2 inhibitors for patients with type 2 diabetes who have 1:

• Established cardiovascular disease
• Heart failure (particularly with reduced ejection fraction)
• Chronic kidney disease

These recommendations are based on significant evidence showing SGLT2 inhibitors reduce:

• Major adverse cardiovascular events (MACE) by 14% 2
• Heart failure hospitalizations by 27-35% 2
• Progression of kidney disease by 32-47% 2

Specific SGLT2 Inhibitors and Their Status

1. Empagliflozin (Jardiance):

   • FDA-approved for reducing cardiovascular death in adults with type 2 diabetes and cardiovascular disease
   • Reduced primary composite cardiovascular outcome by 14% (HR 0.86; 95% CI 0.74-0.99) 2
   • Reduced heart failure hospitalizations by 35% 2

2. Canagliflozin (Invokana):

   • FDA-approved for reducing major cardiovascular events in patients with type 2 diabetes and established cardiovascular disease
   • Reduced primary composite cardiovascular outcome by 14% (HR 0.86; 95% CI 0.75-0.97) 2
   • Reduced risk of end-stage kidney disease by 32% 2

3. Dapagliflozin (Farxiga):

   • FDA-approved for heart failure with reduced ejection fraction and chronic kidney disease
   • Reduced heart failure hospitalizations by 27% 2
   • Effective in patients with and without diabetes 3

Practical Considerations for Medicare Patients

Cost Management Strategies

• Medicare Part D Low-Income Subsidy (Extra Help): Reduces out-of-pocket costs
• Manufacturer assistance programs: May help with copayments
• Formulary exceptions: Physicians can request coverage for non-formulary medications when medically necessary

Common Pitfalls to Avoid

1. Not checking specific plan coverage: Coverage varies significantly between Medicare plans
2. Ignoring prior authorization requirements: Can lead to claim denials
3. Failing to document medical necessity: Documentation of cardiovascular disease, heart failure, or kidney disease improves coverage likelihood
4. Not considering renal function: SGLT2 inhibitors have renal function restrictions 1:
   • Canagliflozin: Not recommended for eGFR <30 mL/min/1.73m²
   • Dapagliflozin: Not recommended for glycemic control if eGFR <45 mL/min/1.73m²
   • Empagliflozin: Not recommended for glycemic control if eGFR <45 mL/min/1.73m²

Conclusion

When prescribing SGLT2 inhibitors for Medicare patients:

1. Verify specific Medicare Part D plan coverage
2. Document cardiovascular, heart failure, or kidney disease to support medical necessity
3. Consider obtaining prior authorization before prescribing
4. Assess renal function to ensure appropriate use
5. Explore cost assistance options if needed for patient affordability