CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Jardiance (empagliflozin) coverage criteria

Defines clinical coverage and prior authorization criteria for Jardiance (empagliflozin) for indications including type 2 diabetes mellitus, heart failure, and chronic kidney disease. Applies to pharmacy/specialty drug benefit reviewers and prescribing providers.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyJardiance (empagliflozin) coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization and document prior optimization or intolerance to metformin and/or dapagliflozin as applicable to support approval for up to 12 months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12maximum authorization duration

1quantity limit (tablets/day)

30minimum recent claim for continuation (days)

Authorization and Continuation Criteria for Jardiance (empagliflozin)

Initial authorization — 12 months

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

ANY of the following

Adjunct to diet and exercise to improve glycemic control in patients 10 years of age or older with type 2 diabetes mellitus AND the patient has not achieved adequate glucose control on a maximized dose and appropriate duration of metformin (2 grams/day) and dapagliflozin.
Document prior use/intolerance/contraindication to metformin and dapagliflozin; wording in source is inconsistent but intent is to require prior optimization of metformin and dapagliflozin.
Used for the treatment of heart failure (NYHA class II-IV).
Chronic kidney disease at risk of progression AND the patient has experienced inadequate outcome, intolerance, or contraindication with dapagliflozin.
Requires prior trial or intolerance/contraindication to dapagliflozin.

Prior Authorization, Documentation, and Denial Risks

Prior Authorization

Prior authorization required with clinical justification

Obtain prior authorization showing the patient meets one of the initial authorization criteria to receive up to 12 months of coverage (optimized metformin and dapagliflozin use for T2DM, heart failure NYHA class II–IV, or CKD with inadequate outcome/intolerance/contraindication to dapagliflozin).

Documentation Required

Document prior therapies and intolerance/contraindications

Document prior trial and inadequate response, intolerance, or contraindication to metformin when treating type 2 diabetes and to dapagliflozin when relevant for the chosen indication (diabetes or chronic kidney disease).

Denial Risk

Risk of non-coverage for lack of evidence of prior trial

Coverage may be denied if records do not show prior optimization of metformin and dapagliflozin when required, or if there is no recent paid Jardiance claim for continuation requests.

Clinical Rationale and Indications

Empagliflozin (Jardiance) is a sodium-glucose co-transporter 2 (SGLT2) inhibitor with multiple clinical uses. It is indicated as an adjunct to diet and exercise to improve glycemic control in patients 10 years of age and older with type 2 diabetes mellitus. It is also indicated to reduce the risk of cardiovascular death in adults with type 2 diabetes mellitus and established cardiovascular disease, and to reduce the risk of cardiovascular death and hospitalization for heart failure in adults with heart failure (NYHA class II–IV). Additionally, empagliflozin is indicated to slow progression of certain kidney diseases, reducing the risk of sustained decline in eGFR, end‑stage kidney disease, cardiovascular death, and hospitalization in adults with chronic kidney disease at risk of progression.