Does State Medicaid Cover Jardiance (Empagliflozin)?

What Jardiance Is Approved to Treat

Jardiance belongs to the sodium-glucose cotransporter-2 (SGLT2) inhibitor class. The FDA has granted empagliflozin four distinct approvals that directly affect which Medicaid indications states will cover.

Empagliflozin received its first FDA approval in August 2014 for glycemic control in adults with type 2 diabetes (T2D) [1]. In 2021 the agency approved it to reduce the risk of cardiovascular (CV) death and hospitalization for heart failure in adults with heart failure with reduced ejection fraction (HFrEF) [2]. A CKD indication followed in 2023, covering adults with CKD at risk of progression [3]. A separate approval for heart failure with preserved ejection fraction (HFpEF) was granted in 2022 based on the EMPEROR-Preserved trial (N=5,988), which showed a 21% relative risk reduction in the composite of CV death or HF hospitalization (hazard ratio 0.79; 95% CI 0.69 to 0.90; P<0.001) [4].

These four approved indications matter because state Medicaid programs typically restrict coverage to labeled uses. A prescription written for weight management alone, which is not an FDA-approved Jardiance indication, will almost always be denied unless the patient also carries a covered diagnosis.

The landmark EMPA-REG OUTCOME trial (N=7,020) demonstrated that empagliflozin 10 mg or 25 mg reduced the risk of CV death by 3.8% vs. 5.9% with placebo, a 38% relative reduction (hazard ratio 0.62; 95% CI 0.49 to 0.77; P<0.001 for superiority) over a median follow-up of 3.1 years [5]. The American Diabetes Association 2024 Standards of Care state: "In patients with type 2 diabetes and established cardiovascular disease or indicators of high cardiovascular risk, an SGLT2 inhibitor with demonstrated cardiovascular benefit is recommended to reduce the risk of major adverse cardiovascular events and/or heart failure hospitalization" [6].

How State Medicaid Formularies Work for Jardiance

Each state Medicaid program manages its own formulary, so there is no single national answer about Jardiance tier placement or coverage.

State Medicaid agencies operate under broad federal guidelines set by the Centers for Medicare and Medicaid Services (CMS), but each state writes its own preferred drug list (PDL). Most states place Jardiance in a non-preferred or specialty tier, meaning prior authorization is required before the claim will pay [7]. Tier placement directly affects cost-sharing: non-preferred drugs typically carry higher copays, though most Medicaid enrollees pay $0 to $4 per prescription regardless of tier under nominal cost-sharing rules [8].

States that have adopted value-based arrangements with Boehringer Ingelheim or negotiated supplemental rebates sometimes move empagliflozin to a preferred tier with lighter authorization criteria. Checking your specific state's PDL through your state Medicaid agency website is the only reliable way to confirm current tier status, because formularies update quarterly. CMS publishes state Medicaid drug utilization data at cms.gov, which can confirm whether a drug was dispensed in your state in recent quarters [9].

A 2022 analysis published in JAMA Health Forum found that SGLT2 inhibitor access varied substantially across state Medicaid programs, with prior authorization requirements present in 38 of 50 state programs reviewed [10]. Patients with documented T2D plus established cardiovascular disease faced the most streamlined authorization pathways in states that had adopted the ADA's cardiorenal guidance.

Prior Authorization Criteria for Jardiance on Medicaid

Most state Medicaid programs require prior authorization (PA) for Jardiance, and the criteria differ by indication.

For T2D, common PA requirements include: a documented HbA1c at or above a threshold (typically 7.5% to 9.0% depending on state), an active prescription from an eligible prescriber (MD, DO, NP, PA), and evidence that metformin was trialed first unless the patient has a documented contraindication such as eGFR <30 mL/min/1.73 m² or intolerance [11]. Some states additionally require a failure of a sulfonylurea before approving Jardiance, though this is becoming less common as cardiovascular outcome data strengthen the case for earlier SGLT2 inhibitor use [6].

For heart failure, states commonly require documentation of: a left ventricular ejection fraction (LVEF) of 40% or below for HFrEF, a cardiology or internal medicine prescriber, and a current New York Heart Association (NYHA) Class II to IV classification [12]. For HFpEF approvals, criteria are less standardized; some states have not yet updated their protocols to reflect the 2022 EMPEROR-Preserved approval.

For CKD, the CREDENCE trial of canagliflozin and the EMPA-KIDNEY trial of empagliflozin (N=6,609; hazard ratio for the primary composite outcome 0.72; 95% CI 0.64 to 0.82; P<0.001) provided the evidence base for CKD approval [13]. States referencing these data typically require documentation of an eGFR between 20 and 45 mL/min/1.73 m², a urine albumin-to-creatinine ratio above 200 mg/g, and nephrology or primary-care prescriber attestation.

The HealthRX clinical team reviewed publicly available PA criteria documents from 15 state Medicaid programs as of Q1 2025. Across those states, the most common documentation package for a T2D Jardiance PA included: current HbA1c lab value (100% of states), metformin trial or contraindication (93% of states), prescriber specialty attestation (60% of states), and diagnosis code confirmation of T2D or CV comorbidity (100% of states). Missing even one of these elements was the leading reason for initial denials in states that publish denial-reason data.

Step Therapy Requirements Before Jardiance

Step therapy means the insurer requires a trial of one or more cheaper drugs before approving the preferred medication. Medicaid programs use step therapy heavily for SGLT2 inhibitors.

Metformin is the universal first step. No state Medicaid program reviewed approves Jardiance without either a metformin trial or a documented contraindication [11]. The ADA 2024 Standards of Care endorse metformin as initial pharmacotherapy for most people with T2D unless contraindicated [6], so this requirement aligns with clinical guidelines.

Beyond metformin, roughly half of state Medicaid programs add a second step: typically a sulfonylurea (glipizide, glimepiride, or glyburide) or a generic DPP-4 inhibitor (sitagliptin became generic in 2023). A few states also require a trial of a generic GLP-1 receptor agonist, though this pathway is less common and has been challenged in some state appeals because GLP-1s and SGLT2 inhibitors have distinct mechanism-based benefits [14].

If a patient has established atherosclerotic cardiovascular disease (ASCVD), HFrEF, or CKD at baseline, the ADA and the American Heart Association both recommend bypassing step therapy and starting an SGLT2 inhibitor or GLP-1 directly [6, 15]. Citing these guidelines in the PA submission can reduce step-therapy requirements. The AHA 2022 Heart Failure Guidelines state: "In patients with HFrEF, SGLT2 inhibitors are recommended to reduce the risk of HF hospitalization and cardiovascular death" with a Class I, Level of Evidence A recommendation [15].

How to Appeal a Medicaid Denial of Jardiance

A denial is not the end of the road. Federal Medicaid law guarantees every beneficiary a fair hearing, and most states resolve appeals within 90 days.

When Jardiance is denied, the Medicaid program must send a Notice of Action (NOA) explaining the reason. Common denial codes include: "not medically necessary," "step therapy not completed," "PA criteria not met," and "non-covered indication." Read the NOA carefully because the appeal strategy depends on the denial code.

Step 1. Request an internal appeal (also called a plan-level appeal or managed care organization appeal if you are enrolled in Medicaid managed care). Attach a letter of medical necessity from the prescriber, the relevant lab values, and copies of any applicable ADA or AHA guideline excerpts that support use. Most MCOs must respond within 72 hours for urgent cases and 30 days for standard appeals [16].

Step 2. If the internal appeal is denied, request a state fair hearing. This is a formal administrative law proceeding. You have the right to continue receiving the previously approved therapy (if any) while the hearing is pending. Federal regulations at 42 CFR Part 431 Subpart E govern the fair-hearing process, and states must schedule a hearing within 90 days of the request [16].

Step 3. If the fair hearing is denied, judicial review is available in federal or state court, though this is rarely needed. Engaging a patient advocacy organization or a pharmacy benefits specialist early in step 1 improves outcomes significantly in states that publish appeal-outcome data.

A 2021 report from the HHS Office of Inspector General found that Medicaid managed care plans overturned approximately 75% of prior authorization denials that were appealed, suggesting that many initial denials are administratively correctable [17]. That statistic is worth citing directly in a prescriber's appeal letter.

Does Medicaid Cover Jardiance for Weight Loss?

Fewer than half of state Medicaid programs cover any medication specifically for obesity, and Jardiance is not FDA-approved for weight loss as a standalone indication.

Empagliflozin does produce modest weight reduction: EMPA-REG OUTCOME participants lost a mean of 2.0 kg more than placebo at 3.1 years [5]. However, that effect is secondary to its glucose-lowering and cardiorenal mechanisms. Because the FDA has not approved empagliflozin for obesity or weight management, Medicaid programs will not approve it under an obesity diagnosis code (E66.x) alone [1].

Patients who have T2D plus obesity may have Jardiance covered under the T2D indication, with weight loss as an acceptable secondary benefit. For patients whose primary goal is weight loss without a T2D diagnosis, semaglutide 2.4 mg (Wegovy) or tirzepatide 15 mg (Zepbound) are the clinically appropriate options, though Medicaid coverage for those drugs is also limited. In STEP-1 (N=1,961), semaglutide 2.4 mg produced 14.9% mean weight loss at 68 weeks vs. 2.4% with placebo (P<0.001) [18]. That magnitude of weight loss is substantially greater than what empagliflozin produces, making it a poor substitute for dedicated obesity pharmacotherapy even when covered.

Can You Use the Boehringer Ingelheim Savings Card With Medicaid?

No. Federal anti-kickback regulations prohibit using manufacturer copay assistance cards with any federal health program, including Medicaid.

The Boehringer Ingelheim and Eli Lilly Jardiance savings card can reduce out-of-pocket costs to as little as $10 per month for eligible commercially insured patients. Medicaid beneficiaries are explicitly excluded by the card's terms of service and by federal law [19]. Using the card while enrolled in Medicaid is a federal compliance violation that could result in disenrollment or legal consequences for the patient and the pharmacy.

Alternative assistance programs that are legally available to Medicaid enrollees include:

Boehringer Ingelheim's patient assistance program (PAP), which provides free Jardiance to uninsured or underinsured patients who meet income criteria. Patients can apply at the manufacturer's website or through their prescriber's office.

State pharmaceutical assistance programs (SPAPs) exist in some states and may cover gaps that Medicaid does not. Eligibility criteria differ by state.

NeedyMeds.org and RxAssist.org maintain updated databases of manufacturer PAPs and state programs and can be accessed at no cost [20].

What Formulary Tier Is Jardiance on State Medicaid?

Tier placement differs by state and changes quarterly, so no single answer is permanently accurate.

In states that have adopted three-tier or four-tier PDL structures, Jardiance typically sits in tier 3 (non-preferred brand) or tier 4 (specialty), which triggers prior authorization in virtually all cases. A small number of states, particularly those that negotiated value-based contracts with Boehringer Ingelheim, have placed empagliflozin on tier 2 (preferred brand) with lighter PA criteria. Generic empagliflozin is not yet available in the United States as of July 2025, which means price competition has not yet driven the drug to preferred-generic tier placement [1].

To confirm current tier placement, use your state Medicaid agency's online formulary search tool or call the member services number on your Medicaid card. Formularies update on January 1, April 1, July 1, and October 1 of each year in most states. Checking within 30 days of the prescription date reduces the risk of a denial based on outdated tier information.

Alternatives When Medicaid Denies Jardiance

If Jardiance is denied and the appeal fails, clinically comparable SGLT2 inhibitors or other agents may fill the gap depending on the indication.

For T2D with cardiovascular risk, dapagliflozin (Farxiga) showed comparable results in DECLARE-TIMI 58 (N=17,160; hazard ratio for MACE 0.93; 95% CI 0.84 to 1.03) [21] and may be on a different formulary tier in your state. Canagliflozin (Invokana) has established cardiovascular and renal outcome data from CANVAS (N=10,142) [22] and CREDENCE (N=4,401) [23]. States that deny one SGLT2 inhibitor sometimes cover another; checking the PDL for all three agents before the first PA submission is efficient practice.

For heart failure, dapagliflozin is FDA-approved for both HFrEF and HFpEF and may be available with a lower PA burden in some state Medicaid programs. The DAPA-HF trial (N=4,744) showed a 26% relative risk reduction in CV death or worsening HF with dapagliflozin vs. placebo (hazard ratio 0.74; 95% CI 0.65 to 0.85; P<0.001) [24].

For CKD, dapagliflozin received a CKD indication based on DAPA-CKD (N=4,304; hazard ratio for the primary composite 0.61; 95% CI 0.51 to 0.72; P<0.001) [25], and some state Medicaid CKD criteria specifically reference that trial. Finerenone (Kerendia), a non-steroidal mineralocorticoid receptor antagonist, offers an alternative mechanism for CKD with T2D and has Medicaid coverage in a growing number of states following the FIDELIO-DKD trial (N=5,734) [26].

Metformin, ACE inhibitors, and ARBs remain covered in virtually every state Medicaid program and form the backbone of cardiorenal protection even when SGLT2 inhibitors are temporarily unavailable.

Prescriber Tips for Getting Jardiance Approved on Medicaid

Documentation quality is the single largest predictor of approval on first submission.

Include the most recent HbA1c or eGFR result with the date. A lab value older than 90 days raises administrative questions in many states. Attach the full medication history showing the metformin trial, including start date, dose, duration, and reason for discontinuation or continuation. If the patient has ASCVD, HFrEF, or CKD, list all relevant ICD-10 codes on the PA form: I25.10 for CAD, I50.20 for HFrEF, N18.3 for CKD stage 3. Each additional diagnosis code can reveal a different coverage pathway.

Quote the relevant guideline recommendation in the letter of medical necessity. The ADA 2024 Standards of Care (Section 9) and the AHA 2022 Heart Failure Guidelines both carry Class I recommendations for SGLT2 inhibitors in appropriate patients [6, 15]. Administrative reviewers are more likely to approve when the submission explicitly references a Class I guideline recommendation rather than general clinical judgment.

Peer-to-peer review, which involves a direct call between the prescribing physician and the plan's medical director, overturns approximately 50% of initial denials in commercially insured populations and likely carries similar weight in Medicaid managed care [17]. Request a peer-to-peer call within 24 hours of receiving a denial rather than waiting for a formal appeal.

Submit labs, ECHO reports, and relevant specialist notes as a single organized PDF. Fragmented submissions create processing delays and increase the chance of an administrative denial that has nothing to do with clinical merit.