Does Aetna (CVS Health) Cover Jardiance (Empagliflozin)?

How Aetna (CVS Health) Places Jardiance on Its Formulary

Aetna categorizes Jardiance as a Tier 3 non-preferred brand drug on the majority of its commercial PPO and HMO formularies, though the exact tier can shift by plan year, employer group contract, and the CVS Caremark preferred drug list in effect at the time of benefit renewal. A Tier 3 placement means the member's copay or coinsurance is meaningfully higher than it would be for a Tier 1 generic or Tier 2 preferred brand, and prior authorization is almost always a condition of coverage before the pharmacy will fill the prescription.

The CVS Caremark National Formulary, which underlies most Aetna commercial plans, publishes its preferred and non-preferred SGLT2 inhibitor list each January. For 2024 and into 2025, generic empagliflozin has not yet entered the U.S. market, so brand Jardiance holds its position as the reference product. The FDA approved empagliflozin for type 2 diabetes in August 2014, for heart failure with reduced ejection fraction (HFrEF) in August 2021, and for chronic kidney disease (CKD) in July 2023 [1]. Each new indication can trigger a separate PA review because Aetna's clinical policy bulletins address each diagnosis independently.

Employers who self-fund their health benefits through Aetna can and do modify the standard formulary, so a patient's actual tier and PA status must be confirmed by calling the member services number on the insurance card or by using Aetna's online formulary search tool at aetna.com. [2]

Prior Authorization Criteria: What Aetna Typically Requires

Prior authorization for Jardiance on Aetna commercial plans is moderate-to-high in complexity. The prescriber must submit clinical documentation showing the patient meets specific criteria that track closely to FDA labeling and, for cardiovascular and renal indications, to published guidelines from the American Diabetes Association [3] and the American College of Cardiology [4].

For a type 2 diabetes indication, Aetna's PA criteria generally require:

1. A confirmed diagnosis of type 2 diabetes (not type 1).
2. Documentation of an HbA1c at or above a plan-specified threshold, typically 7.0% to 7.5%.
3. Evidence of a trial of metformin at a maximally tolerated dose, unless a documented contraindication exists (renal impairment with eGFR <30 mL/min/1.73m², intolerance, or lactic acidosis risk).
4. Prescriber attestation that the patient has established atherosclerotic cardiovascular disease (ASCVD), heart failure, or CKD, or that cardiovascular risk is high enough to justify an SGLT2 inhibitor per the ADA Standards of Care.

For the heart failure indication, Aetna typically asks for documentation of a left ventricular ejection fraction (LVEF) at or below 40%, current guideline-directed medical therapy (GDMT) including a beta-blocker and an ACE inhibitor/ARB/ARNI, and NYHA functional class II or III symptoms. The EMPEROR-Reduced trial (N=3,730) showed empagliflozin 10 mg reduced the composite of cardiovascular death or hospitalization for heart failure by 25% relative to placebo (hazard ratio 0.75; 95% CI 0.65 to 0.86; P<0.001) [5]. Citing that trial outcome directly in the PA request letter strengthens the clinical justification.

For the CKD indication, an eGFR between 20 and 45 mL/min/1.73m² with urine albumin-to-creatinine ratio (UACR) above 200 mg/g is the profile most consistent with the EMPA-KIDNEY trial population (N=6,609), which showed a 28% relative risk reduction in the primary composite of kidney disease progression or cardiovascular death (hazard ratio 0.72; 95% CI 0.64 to 0.82; P<0.001) [6]. Aetna reviewers are more likely to approve when the clinical note maps directly to that trial's enrollment criteria.

A prescriber who submits a PA with all four required elements in a single fax typically sees a decision within 2 to 3 business days on standard review, or within 72 hours on urgent review. Incomplete submissions are the single most common reason for delays, not outright clinical denials.

Step Therapy Requirements Before Jardiance

Step therapy is the rule for Aetna's Jardiance PA, not the exception. For the type 2 diabetes indication, Aetna requires documented failure of or contraindication to metformin, and in some plan designs, a trial of a preferred lower-cost agent such as a sulfonylurea (e.g., glipizide) or, where available, a preferred formulary SGLT2 inhibitor. [7]

The 2024 ADA Standards of Care explicitly state that in patients with type 2 diabetes and established cardiovascular disease, heart failure, or CKD, an SGLT2 inhibitor with demonstrated cardiovascular or renal benefit should be started independent of background glucose control, meaning metformin is not a prerequisite in those populations [3]. This is the single most important clinical argument to include when a step-therapy requirement is blocking access for a high-risk patient.

Prescribers should note that step therapy for CKD and HFrEF indications may be waived more readily than for uncomplicated type 2 diabetes, because no equivalent alternative exists at the same evidence level. Quoting the ADA guideline language verbatim in the PA request letter has, in clinical practice, supported faster approvals for these higher-acuity cases.

What the EMPA-REG OUTCOME Trial Means for Your PA Request

The EMPA-REG OUTCOME trial (N=7,020) published in the New England Journal of Medicine in 2015 remains the foundational cardiovascular outcomes trial for empagliflozin [8]. Patients with type 2 diabetes and established cardiovascular disease who received empagliflozin 10 mg or 25 mg had a 38% relative risk reduction in cardiovascular death compared with placebo (10.5% vs. 5.9% over a median 3.1 years; hazard ratio 0.62; 95% CI 0.49 to 0.77; P<0.001 for superiority). Hospitalization for heart failure was reduced by 35% (hazard ratio 0.65; 95% CI 0.50 to 0.85; P=0.002) [8].

Aetna's clinical policy bulletins acknowledge cardiovascular outcomes trial data as relevant evidence. A PA letter that states the patient has documented ASCVD, cites EMPA-REG OUTCOME by name, and ties that to the FDA's cardiovascular risk reduction labeling [1] gives the reviewing pharmacist or physician an on-label, evidence-backed reason to approve. Plans that deny despite this evidence are the ones most vulnerable to appeal reversal.

The EMPA-KIDNEY investigators also found that empagliflozin's kidney-protective effects were consistent regardless of baseline diabetes status, supporting use in CKD patients without type 2 diabetes [6]. That broader population may still face off-label barriers with some Aetna plan designs, because FDA labeling for the CKD indication does not require diabetes as a co-diagnosis. [9]

Step-by-Step: How to Appeal an Aetna Jardiance Denial

Aetna denials for Jardiance are not final. Federal law under the Affordable Care Act and ERISA requires insurers to offer at least one internal appeal and access to independent external review. [10]

Step 1: Request the Denial Letter The denial letter must state the specific clinical criteria the request failed to meet. Aetna is required to provide this within 3 business days for urgent requests or 15 days for standard PA decisions. [10]

Step 2: File the First-Level Internal Appeal The prescriber or patient submits a written appeal with supporting clinical documentation. Include the full office note, lab values (HbA1c, eGFR, UACR, LVEF as applicable), the relevant trial citations (EMPA-REG OUTCOME [8], EMPEROR-Reduced [5], EMPA-KIDNEY [6]), and the ADA Standards of Care guideline text [3]. Aetna must decide within 30 days for pre-service standard appeals or 72 hours for urgent appeals.

Step 3: Second-Level Internal Appeal (If Offered) Some Aetna plan designs allow a second internal review. Use this round to request a peer-to-peer call between the prescriber and Aetna's reviewing physician. Peer-to-peer calls are associated with a meaningfully higher reversal rate than written appeals alone, particularly when the prescriber can quote specific trial outcomes.

Step 4: External Independent Review If the internal appeal is denied, the patient has the right to request external review through an independent review organization (IRO) designated by the state or, for self-funded ERISA plans, by the federal external review process. The IRO's decision is binding on the insurer for fully insured plans. External review overturns insurer denials approximately 40% of the time for specialty medications with strong guideline support, based on data compiled by state departments of insurance [11].

Step 5: State Insurance Commissioner Complaint Filing a complaint with the state insurance commissioner while the appeal is active creates a regulatory record and sometimes prompts faster internal resolution. This step costs nothing and takes approximately 15 minutes online.

Using the Jardiance Manufacturer Savings Card with Aetna

The Lilly and Boehringer Ingelheim Jardiance Savings Card (sometimes called the Jardiance Copay Savings Card) is available to commercially insured patients who are not enrolled in Medicare, Medicaid, or any other federally funded health program. [12] Eligible Aetna commercial plan members may pay as little as $10 per 30-day fill through participating pharmacies, subject to a maximum annual benefit that varies by program year.

The savings card does not apply to Medicare Part D plans, Medicare Advantage Prescription Drug plans, or Medicaid managed care plans. Patients on those plans must pursue a different cost-reduction pathway, such as applying for the Lilly Cares Foundation patient assistance program or requesting a Medicare Part D Low Income Subsidy (LIS/Extra Help). [13]

One common error: some pharmacies attempt to run the savings card alongside the Aetna benefit rather than as a secondary layer, which can trigger a coordination-of-benefits rejection. The correct workflow is to run the Aetna insurance first, then apply the savings card to the remaining out-of-pocket balance.

Does Aetna Cover Jardiance for Weight Loss?

No. As of mid-2025, empagliflozin does not hold an FDA approval for weight management or obesity, and Aetna will not cover it under a weight-loss indication [1]. Average weight reduction with empagliflozin in clinical trials is approximately 2 to 3 kg over 24 weeks, a meaningful but modest effect compared with the 14.9% mean body weight reduction seen in STEP-1 (N=1,961) with semaglutide 2.4 mg at 68 weeks [14]. Off-label prescribing for weight loss will be denied at PA, and an appeal on that basis is unlikely to succeed without an on-label co-diagnosis such as type 2 diabetes or heart failure.

Patients who have both obesity and type 2 diabetes may be covered for Jardiance under the diabetes indication. Weight reduction in that context is a secondary clinical benefit, not a coverage trigger. The prescriber should document the primary diabetes indication and not list weight loss as the reason for the medication.

Formulary Alternatives Aetna May Prefer Over Jardiance

Aetna's CVS Caremark formulary may designate a competing SGLT2 inhibitor as preferred over Jardiance in a given plan year. Canagliflozin (Invokana) and dapagliflozin (Farxiga) are the two most likely alternatives. Dapagliflozin holds FDA approvals for type 2 diabetes, heart failure (both HFrEF and HFpEF), and CKD, and its cardiovascular outcome data from DECLARE-TIMI 58 (N=17,160) and renal data from DAPA-CKD (N=4,304) are cited in major guidelines [15, 16]. If a patient's plan has dapagliflozin as the preferred SGLT2 inhibitor, switching may be clinically reasonable and eliminates the step therapy barrier.

Prescribers should check whether the specific clinical indication maps well to the alternative drug's label before switching. For example, only empagliflozin and dapagliflozin currently hold CKD indications without requiring diabetes as a co-diagnosis; canagliflozin's CKD label (CREDENCE trial, N=4,401) requires type 2 diabetes [17]. Choosing the wrong alternative can create a second coverage gap.

How to Confirm Current Aetna Jardiance Coverage Before Prescribing

Coverage details shift each plan year, and individual employer contracts can override the standard CVS Caremark National Formulary. Before sending a Jardiance prescription, take these concrete steps:

1. Call Aetna member services (number on the back of the insurance card) and ask for the drug's tier, copay or coinsurance, and whether PA is required for the specific ICD-10 code you are using (E11.x for type 2 diabetes, I50.2x for HFrEF, N18.x for CKD).
2. Use the Aetna online formulary search at aetna.com with the patient's plan ID and the drug name "empagliflozin" to see the 2025 tier placement.
3. Ask the specialty pharmacy or retail pharmacy to run an eligibility check before dispensing. A real-time eligibility check takes under 60 seconds and surfaces the PA requirement flag before the prescription is adjudicated.
4. Download Aetna's applicable clinical policy bulletin for SGLT2 inhibitors. These are publicly available on aetna.com under "Clinical Policy Bulletins" and detail the exact PA criteria in effect for the current policy period. [2]

These steps together take about 10 minutes and prevent the patient from arriving at the pharmacy to find an unexpected $680 cash-price bill.