Does Humana Cover Jardiance (Empagliflozin)?

What FDA Indications Does Jardiance Carry, and Why Does That Matter for Coverage?

Humana's coverage decisions follow the FDA label almost line by line, so knowing every approved indication before you call the pharmacy benefit line can prevent an unnecessary denial. Jardiance holds FDA approval for glycemic control in adults with type 2 diabetes, reduction of cardiovascular death in adults with type 2 diabetes and established cardiovascular disease, reduction of hospitalization for heart failure in adults with HFrEF and HFpEF, and slowing progression of chronic kidney disease in adults at risk of progression. [1][2]

Empagliflozin belongs to the sodium-glucose cotransporter-2 (SGLT2) inhibitor class. By blocking SGLT2 in the proximal tubule, it reduces renal glucose reabsorption, lowers blood pressure, reduces cardiac preload, and has direct tubuloglomerular feedback effects that lower intraglomerular pressure. [3] Each of these mechanisms underpins a separate trial program, and insurers treat each indication separately when reviewing prior authorization requests.

The EMPA-REG OUTCOME trial (N=7,020 adults with type 2 diabetes and established cardiovascular disease) showed a 38% relative risk reduction in cardiovascular death with empagliflozin 10 mg or 25 mg versus placebo over a median 3.1 years of follow-up. [4] That landmark result led CMS to recognize the cardiovascular-death indication as clinically necessary, which in turn made Humana Medicare Advantage plans far less likely to deny coverage for patients with documented atherosclerotic cardiovascular disease compared with patients seeking coverage for glycemic control alone.

The EMPEROR-Reduced trial (N=3,730) demonstrated that empagliflozin 10 mg reduced the composite of cardiovascular death or hospitalization for heart failure by 25% versus placebo (hazard ratio 0.75; 95% CI 0.65, 0.86; P<0.001). [5] The EMPEROR-Preserved trial (N=5,988) extended this benefit to patients with HFpEF, with a 21% relative risk reduction in the primary composite (HR 0.79; 95% CI 0.69, 0.90; P<0.001). [6] Coverage reviewers at Humana cite both trials when evaluating heart failure PA requests.

For CKD, the EMPA-KIDNEY trial (N=6,609) stopped early for efficacy: empagliflozin 10 mg reduced the risk of kidney disease progression or cardiovascular death by 28% (HR 0.72; 95% CI 0.64, 0.82; P<0.001) versus placebo. [7] KDIGO 2022 guidelines now recommend SGLT2 inhibitors for adults with CKD and eGFR 20 to 45 mL/min/1.73 m² even in the absence of type 2 diabetes. [8] Including that guideline reference in the PA letter is one of the most effective ways to support approval for a CKD-only indication.

How Does Humana's Formulary Place Jardiance?

Formulary tier placement directly controls your copay and whether a PA is required. Jardiance lands on Tier 3 (preferred brand) or Tier 4 (non-preferred brand) across most Humana commercial plans, and on Tier 4 or Tier 5 on most Medicare Advantage Part D plans, based on Humana's publicly posted 2024 formulary documents. [9]

Tier 3 on a typical Humana commercial plan carries a 30-day copay of $50, $90 after the deductible. Tier 4 runs $90, $150 per 30-day supply. On a Humana Medicare Advantage plan, Tier 4 copays commonly sit at $100, $150 in the initial coverage phase, then shift to 25 to 33% coinsurance in the coverage gap. Once a beneficiary reaches catastrophic coverage (out-of-pocket threshold of $2 to 000 in 2025 under the Inflation Reduction Act cap), cost share drops to $0. [10]

Formulary tiers can change at annual plan renewal. The most reliable way to confirm the current tier for your specific plan is to enter the Humana plan ID and the Jardiance NDC into Humana's online formulary search tool or call 1-800-457-4708. Pharmacists can also run a real-time formulary check with the plan's pharmacy benefit manager.

What Are Humana's Prior Authorization Criteria for Jardiance?

Prior authorization is required on virtually all Humana plans that cover Jardiance. The core clinical criteria differ by indication and map closely to FDA labeling and major guideline statements.

Type 2 diabetes indication. Humana's PA criteria for Jardiance in T2D typically require: (1) a confirmed diagnosis of type 2 diabetes, (2) HbA1c above a threshold (commonly 7.0 to 8.0% depending on the plan), (3) documentation that metformin is contraindicated, not tolerated, or was trialed at an adequate dose, and (4) prescriber attestation that the patient has established cardiovascular disease, is at high cardiovascular risk, or has CKD, factors that align with ADA Standards of Care guidance recommending SGLT2 inhibitors independent of HbA1c when cardiorenal benefit is present. [11]

Heart failure indication. For HFrEF or HFpEF, Humana PA criteria generally require: (1) a diagnosis of symptomatic heart failure confirmed by imaging (echocardiography documenting ejection fraction), (2) stable guideline-directed medical therapy on an ACE inhibitor, ARB, or sacubitril-valsartan plus a beta-blocker, and (3) documentation of NYHA class II, III symptoms. The 2022 AHA/ACC/HFSA heart failure guideline gives SGLT2 inhibitors a Class I recommendation for HFrEF and a Class IIa recommendation for HFpEF. [12] Quoting this directly in the PA letter strengthens the submission.

CKD indication. Criteria commonly include: (1) CKD stage G3a, G4 (eGFR 20 to 60 mL/min/1.73 m²), (2) urine albumin-to-creatinine ratio above 200 mg/g (some plans use 300 mg/g), and (3) concurrent use of a maximally tolerated ACE inhibitor or ARB unless contraindicated. Including the EMPA-KIDNEY citation [7] and the KDIGO 2022 CKD guideline [8] in the PA packet substantially improves approval rates.

A straightforward PA submission for Jardiance should include: the specific FDA indication being requested, recent labs (HbA1c within 90 days for T2D, eGFR and UACR within 6 months for CKD, echocardiogram report for HF), a list of prior therapies with dates and reason for discontinuation if step therapy applies, and direct citation of the supporting guideline with the guideline class recommendation. Incomplete submissions are the most common reason for first-pass denials in Humana's prior authorization queue.

Does Humana Require Step Therapy Before Approving Jardiance?

Step therapy is common on the T2D indication and rare on the cardiovascular-death and heart failure indications. For T2D glycemic control specifically, most Humana commercial and Medicare Advantage plans require at least one trial of metformin at a dose of 1 to 000 mg twice daily for 90 days or more, unless the patient has a documented contraindication (eGFR <30 for metformin), intolerance, or an immediate cardiorenal indication that supports bypassing step therapy. [11]

If your patient has documented atherosclerotic cardiovascular disease, the ADA recommends starting an SGLT2 inhibitor or GLP-1 receptor agonist regardless of HbA1c level and regardless of prior metformin use. [11] That ADA language is frequently the most persuasive text for bypassing step therapy. Attach the relevant ADA Standards of Care table to the PA letter and note the patient's ASCVD risk score.

Step therapy exemptions vary by state. Several states, including Texas, New York, and California, have enacted step therapy protection laws requiring insurers to grant exceptions when a clinician documents that the required first-step drug is contraindicated, expected to cause harm, or has already been tried. [13] If Humana invokes step therapy in one of these states and your patient meets exemption criteria, cite the relevant state statute in the appeal.

Does Humana Cover Jardiance for Weight Loss?

No. Jardiance is not FDA-approved for weight loss. CMS prohibits Medicare Advantage plans from covering drugs for weight loss unless the drug carries a separate FDA approval for an obesity indication. [14] Because empagliflozin does not hold that approval, Humana Medicare Advantage plans cannot cover it for weight management, regardless of the weight benefit seen in clinical practice.

On commercial Humana plans, coverage for off-label weight loss use is also generally excluded, as Humana's medical policy follows FDA labeling for on-formulary coverage. Patients seeking pharmacotherapy for obesity should ask about dedicated GLP-1/GIP agonists that carry an FDA obesity indication, such as semaglutide 2.4 mg (Wegovy) or tirzepatide 2.5 to 15 mg (Zepbound).

How Do I Appeal a Humana Denial of Jardiance?

A denial is not the end of the road. Humana's appeal process has defined timelines, and a well-constructed appeal reverses a meaningful share of denials.

Step 1: Internal reconsideration. After a denial, Humana allows a prescriber-requested reconsideration (also called a peer-to-peer call) within 24 to 72 hours of the denial notice. On this call, the treating physician speaks directly with the Humana medical director who denied the claim. Arriving with labs, the indication-specific guideline citation, and trial data (EMPA-REG OUTCOME [4], EMPEROR-Reduced [5], EMPA-KIDNEY [7]) converts a significant share of denials to approvals at this stage.

Step 2: Formal internal appeal. If the peer-to-peer fails, the patient or prescriber submits a written Level 1 appeal within 60 days of the denial notice for commercial plans, or within 60 days for Medicare Advantage plans. Attach the full clinical record, PA documentation, and a letter citing the ADA [11] and ACC/AHA [12] guidelines by name and class of recommendation.

Step 3: Medicare Advantage external review. For Medicare Advantage members, a denied Level 1 appeal goes to MAXIMUS Federal Services, the independent review entity contracted by CMS. MAXIMUS must issue a standard review decision within 60 days or an expedited decision (for urgent medical need) within 72 hours. [15] CMS data from 2022 show that beneficiaries who pursued external review prevailed in approximately 40 to 45% of cases across all drug classes. [16]

Step 4: ALJ and further escalation. If MAXIMUS upholds the denial, the member may request an Administrative Law Judge hearing if the amount in controversy meets the minimum threshold ($180 in 2025). [15] This path is rarely necessary for Jardiance given success rates at earlier levels, but it exists.

When writing the appeal letter, avoid vague language. State the indication precisely ("reduction of hospitalization for heart failure in a patient with HFpEF documented by echocardiogram on [date], LVEF 55%, NYHA Class II symptoms"), cite the guideline class recommendation verbatim, and attach the echocardiogram or relevant lab report as an exhibit.

Can Patients Use the Boehringer Ingelheim Jardiance Savings Card With Humana?

The Boehringer Ingelheim and Eli Lilly savings card for Jardiance can reduce out-of-pocket costs to as low as $10 per month for eligible commercially insured patients. [17] The card is not valid for patients enrolled in any federal health care program, including Medicare, Medicaid, TRICARE, or VA coverage. Humana commercial plan members who meet the eligibility criteria can apply the savings card at the point of sale through most retail pharmacies.

To activate the savings card, patients enroll at the Jardiance manufacturer website or call the savings program line directly. Eligibility is verified at the pharmacy. The savings program has a maximum annual benefit cap (commonly $1,800, $3,600 per year depending on program terms), so patients should confirm the current cap when enrolling. [17]

Patients on Humana Medicare Advantage Part D plans cannot legally use manufacturer copay cards as primary payment. The Anti-Kickback Statute prohibits manufacturers from offering cost-sharing assistance to Medicare beneficiaries. Some patient assistance programs through the manufacturer may be available for low-income Medicare patients who do not qualify for Extra Help (LIS). [18]

What Is the Out-of-Pocket Cost of Jardiance Without Insurance Through Humana?

The wholesale acquisition cost for Jardiance is approximately $680 per month for a 30-day supply of either the 10 mg or 25 mg dose. Without insurance coverage, most patients pay close to that list price at retail pharmacies, though GoodRx and similar discount programs can reduce the cash price to approximately $450, $550 at some pharmacy chains.

Patients who do not qualify for the manufacturer savings card and face a Humana denial may consider the Boehringer Ingelheim patient assistance program, which provides free medication to qualifying uninsured or underinsured patients based on income. Applications are available through the NeedyMeds database and the manufacturer directly. [19]

How Does Empagliflozin Compare to Other SGLT2 Inhibitors on Humana Formularies?

Dapagliflozin (Farxiga) and canagliflozin (Invokana) are the other SGLT2 inhibitors most commonly seen on Humana formularies. On some Medicare Advantage plans, dapagliflozin sits on a lower tier because of negotiated rebate agreements, making it less expensive out-of-pocket even though the two drugs have overlapping indications.

The DAPA-HF trial (N=4,744) showed dapagliflozin 10 mg reduced cardiovascular death or worsening heart failure by 26% (HR 0.74; 95% CI 0.65, 0.85; P<0.001) in HFrEF patients, a result comparable in magnitude to the EMPEROR-Reduced data for empagliflozin. [20] The CREDENCE trial (N=4,401) with canagliflozin showed a 30% reduction in the primary renal composite (HR 0.70; 95% CI 0.59, 0.82; P=0.00001) in T2D patients with CKD. [21]

If Humana denies Jardiance specifically and the patient's prescriber is open to a therapeutic alternative, dapagliflozin or canagliflozin may be covered at a lower tier or without prior authorization on the patient's specific plan. A formulary exception request for Jardiance over a covered SGLT2 inhibitor requires documentation that the patient tried the preferred alternative and experienced an adverse effect or inadequate response, or that a clinical difference exists between the agents for that patient's specific condition.

What Documentation Should the Prescribing Clinician Prepare Before Calling Humana?

Preparation reduces call time and increases first-call resolution rates. Before initiating a PA request or peer-to-peer call with Humana, the prescribing clinician should have ready: the patient's most recent HbA1c and eGFR with collection dates, UACR if CKD is the primary indication, echocardiogram report with ejection fraction if HF is the primary indication, a medication history listing prior SGLT2 inhibitors or other agents tried with start and stop dates, the specific ICD-10 code (E11.65 for T2D with hyperglycemia, I50.1 for HFrEF, N18.3, N18.4 for CKD stages 3, 4), and printouts or bookmarked URLs for EMPA-REG OUTCOME [4], EMPEROR-Reduced [5], EMPA-KIDNEY [7], ADA Standards of Care [11], and AHA/ACC/HFSA 2022 Heart Failure Guideline. [12]

Submitting all of this in the initial PA package, rather than waiting for Humana to request it, cuts the average PA review cycle from 3 to 7 days to 1 to 3 days in most commercial plan processing queues. [22]