What SGLT2 (Sodium-Glucose Linked Transporter 2) inhibitors are covered by Medicare for patients with type 2 diabetes?

SGLT2 Inhibitors Covered by Medicare

Medicare Part D covers all four FDA-approved SGLT2 inhibitors—canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin—though specific coverage and tier placement varies by individual Medicare Part D plan. 1

Available SGLT2 Inhibitors with Proven Benefits

The following SGLT2 inhibitors have demonstrated cardiovascular and renal benefits in major clinical trials and are FDA-approved for type 2 diabetes:

Empagliflozin (Jardiance)

• Standard dose: 10 mg once daily 1, 2
• FDA-approved to reduce cardiovascular death in patients with type 2 diabetes and established cardiovascular disease 3
• Demonstrated 38% reduction in cardiovascular death (HR 0.62) and 32% reduction in all-cause mortality (HR 0.68) 1, 2
• Can be initiated down to eGFR 45 mL/min/1.73 m² 2

Canagliflozin (Invokana)

• Standard dose: 100 mg once daily 1, 2
• FDA-approved for reducing risk of end-stage kidney disease in diabetic nephropathy with albuminuria 2
• Showed 14% reduction in MACE (HR 0.86) and 33% reduction in heart failure hospitalization (HR 0.67) 1
• Can be initiated down to eGFR 30 mL/min/1.73 m² 2
• Caution: Increased amputation risk in CANVAS trial, particularly in patients with prior amputation, peripheral vascular disease, neuropathy, or diabetic foot ulcers 1

Dapagliflozin (Farxiga)

• Standard dose: 10 mg once daily 1, 2
• Demonstrated benefits in heart failure with reduced ejection fraction, including in patients without diabetes 1
• Showed 27% reduction in heart failure hospitalization (HR 0.73) 1
• Can be initiated down to eGFR 30 mL/min/1.73 m² 2

Ertugliflozin (Steglatro)

• FDA-approved for type 2 diabetes 4, 5
• Less extensive cardiovascular outcomes data compared to the other three agents 4

Clinical Indications for SGLT2 Inhibitors

SGLT2 inhibitors should be initiated based on cardiovascular and renal risk, independent of baseline HbA1c or glycemic control: 1, 6

Highest Priority Patients (Strongest Evidence)

• Established atherosclerotic cardiovascular disease (prior MI, stroke, revascularization) 1
• Heart failure with reduced ejection fraction (EF <45%) 1, 6
• Chronic kidney disease with eGFR 30-60 mL/min/1.73 m² or albuminuria (especially UACR >300 mg/g) 1, 6

High-Risk Patients Without Established CVD

• Age ≥55 years with coronary, carotid, or lower extremity artery stenosis >50% 1
• Left ventricular hypertrophy 1
• eGFR <60 mL/min/1.73 m² or albuminuria 1

Practical Initiation Guidelines

Before starting an SGLT2 inhibitor: 1, 2

• Check eGFR: Empagliflozin requires eGFR ≥45; canagliflozin and dapagliflozin can be used down to eGFR 30 2
• Assess volume status: Consider reducing loop diuretic dose by 50% in patients on high-dose diuretics 2
• Reduce insulin dose by approximately 20% and consider discontinuing sulfonylureas to prevent hypoglycemia 1, 2
• Screen for foot ulcers or amputation risk (particularly for canagliflozin) 1

Patient education must include: 1, 2

• Increased risk of genital yeast infections (most common adverse effect) 7, 8, 4
• Proper genital hygiene 2
• Sick day protocol: Temporarily withhold SGLT2 inhibitor during acute illness, excessive exercise, or alcohol intake to prevent euglycemic diabetic ketoacidosis 1, 2
• Withhold at least 2 days before surgery or procedures requiring bowel preparation 1

Medicare Coverage Considerations

All four SGLT2 inhibitors are typically covered by Medicare Part D plans, but: 1

• Tier placement varies by plan (typically Tier 3 or 4, requiring higher copays)
• Prior authorization may be required depending on the specific plan
• Step therapy requirements may mandate metformin trial first in some plans
• Patients should check their specific Medicare Part D formulary or contact their plan directly for exact coverage details

Common Pitfalls to Avoid

• Do not withhold SGLT2 inhibitors due to modest eGFR decline after initiation—an acute drop in eGFR is expected and generally not a reason to discontinue 1
• Do not wait for inadequate glycemic control to initiate SGLT2 inhibitors in high-risk patients; cardiovascular and renal benefits occur independent of glucose lowering 1, 6
• Do not use SGLT2 inhibitors in type 1 diabetes (except dapagliflozin in Europe as adjunct to insulin) 3, 5
• Avoid in patients with severe renal impairment (eGFR <30), end-stage renal disease, or dialysis 1, 2