Prior Authorization for Jardiance (Empagliflozin)
Whether prior authorization is required for Jardiance depends entirely on your specific health insurance plan, as PA requirements vary significantly between insurers and even between different plan types within the same insurance company.
Understanding Prior Authorization Variability
Prior authorization (PA) is a utilization management strategy used by health plans to ensure cost-effective care, but requirements differ substantially across insurance types 1:
- Marketplace plans require PA for the most medications (440 medications on average), followed by Medicare plans (272 medications), commercial plans (271 medications), and Medicaid plans (72 medications) 2
- Antidiabetic medications like Jardiance represent approximately 9% of all medications potentially requiring PA across insurance plans 2
- Only 25% of medications require PA across 3 or more plan types, and only 5% require PA across all 4 insurance types, demonstrating substantial variation 2
Clinical Context: Why Jardiance May Face PA Requirements
Despite strong clinical evidence supporting empagliflozin's use, insurers may impose PA due to cost considerations 3:
- SGLT2 inhibitors including empagliflozin have median monthly costs of $627 (AWP) or $501 (NADAC) for the maximum approved daily dose 3
- This contrasts sharply with older diabetes medications like metformin ($2-3 monthly) or sulfonylureas ($4-11 monthly) 3
- Empagliflozin has demonstrated cardiovascular benefits with 38% reduction in cardiovascular death and significant reductions in heart failure hospitalization in patients with established cardiovascular disease 3
How to Determine PA Requirements for Your Patient
Check directly with the patient's specific insurance plan through one of these methods:
- Contact the insurance company's pharmacy benefits department before prescribing to verify current PA requirements
- Use your electronic prescribing system, which often flags medications requiring PA in real-time
- Have your office staff call the plan with the patient's member ID to confirm coverage details 1
Consequences of PA Requirements
When PA is required but not obtained or approved 4:
- Patients who do not receive their requested diabetes medication (due to PA denial or abandonment) have significantly smaller HbA1c reductions (-0.4%) compared to those who receive the medication (-0.9% to -1.0%) 4
- Health disparities exist: Hispanic/Latino patients, those with non-integrated system prescribers, and those with higher chronic disease burden are more likely to not receive their requested medication after PA 4
- Administrative burden is substantial, with PA processes causing delays in patient care even when ultimately approved 5
Clinical Recommendation When PA Is Required
If PA is required for Jardiance, provide robust clinical justification emphasizing 3:
- Presence of established cardiovascular disease or high cardiovascular risk (age ≥55 with coronary, carotid, or lower-extremity stenosis ≥50%)
- Presence of heart failure or chronic kidney disease
- Documented cardiovascular benefits independent of glycemic control
- FDA indication for reducing cardiovascular death in adults with type 2 diabetes and cardiovascular disease 3
The American Diabetes Association recommends SGLT2 inhibitors with demonstrated cardiovascular benefit (including empagliflozin) as part of the glucose-lowering regimen independent of A1C and independent of metformin use in patients with established cardiovascular disease, heart failure, or chronic kidney disease 3.