CurrentUnitedHealthcarePolicy P 2247-19

Prior Authorization/Medical Necessity Custom Oxford SoNY and SoCT SGLT2 Inhibitors

UnitedHealthcare prior authorization/medical necessity program for SGLT2 inhibitors (specific agents and combinations) defining step/failure criteria for indications including heart failure, chronic kidney disease with/without diabetes, and glycemic control; includes continuation/automated approvals and authorization durations. Applies to specified commercial/Oxford plans with program-specific effective dates and state mandate notes.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization/Medical Necessity Custom Oxford SoNY and SoCT SGLT2 Inhibitors

Policy CodePolicy P 2247-19

Change TypeAnnual review; added Brenzavvy and Inpefa; clarified authorized_generic labeling

Effective DateOct 12, 2025

Next Review Date

Key ActionDocument history of therapeutic failure, contraindication, or intolerance to specified prior agents (e.g., Jardiance 30-day trial for heart failure/Inpefa; three-month trials for metformin, Jardiance, Synjardy as specified) when requesting authorization.

POLICY UPDATE CHANGES

Added Brenzavvy (bexagliflozin) to criteria.

Added Inpefa (sotagliflozin) to criteria.

Annual review and updated excluded products; clarified authorized_generic labeling for bexagliflozin.

12+Medications referenced

12 monthsTypical authorization duration

30d / 3moRequired prior trial durations (Jardiance / other)

Coverage Summary

Scope: UnitedHealthcare prior authorization/medical necessity program for SGLT2 inhibitors covering specified agents and combination products for indications including glycemic control in type 2 diabetes, heart failure, and chronic kidney disease (with and without diabetes). Applies to specified commercial/Oxford plans with program-specific effective dates and may be modified by state mandates (e.g., Connecticut).

Coverage stance: covered_with_criteria — agents are covered when the policy's step/failure criteria are met (prior trials, intolerance, or contraindication as specified).

Subject: SGLT2 inhibitors prior authorization/medical necessity.

Status and dates: CURRENT; Effective date: 2025-10-12; Last review: 2025-07.

Quick facts and thresholds

Medications referenced12+ (multiple SGLT2 agents and combinations listed, e.g., Brenzavvy/bexagliflozin, Farxiga, Jardiance, Invokana, Glyxambi, Inpefa, Steglatro, combinations: Invokamet/Invokamet XR, Synjardy/Synjardy XR, Xigduo XR, Segluromet, Qtern, Steglujan)

Typical authorization duration12 months

Required prior trial durations (Jardiance / other agents)30 days / 3 months

Threshold - Jardiance trial (heart failure / Inpefa)30-day trial required before Farxiga or Inpefa approval

Threshold - Other agents (metformin / Jardiance / Synjardy etc.)Therapeutic failure or suboptimal response typically after a three-month trial

Initial Therapy Criteria

Heart failure

Farxiga or Inpefa will be approved when the following is met:

ALL of the following

History of therapeutic failure, contraindication or intolerance to a 30-day trial of Jardiance30-day trial

Preserve 30-day Jardiance trial requirement for heart failure/Inpefa

Chronic kidney disease without diabetes

Farxiga will be approved when ALL of the following are met:

ALL of the following

ONE of
- History of suboptimal response, contraindication or intolerance to an angiotensin converting enzyme (ACE) inhibitor (e.g., lisinopril)
- History of suboptimal response, contraindication or intolerance to an angiotensin receptor blocker (ARB) (e.g., losartan)
History of therapeutic failure (after a three-month trial), contraindication or intolerance to Jardiancethree-month trial

Authorization typically issued for 12 months

Chronic kidney disease with diabetes

Farxiga or Invokana will be approved when ALL of the following are met:

ALL of the following

ONE of
- History of suboptimal response, contraindication or intolerance to an angiotensin converting enzyme (ACE) inhibitor (e.g., lisinopril)
- History of suboptimal response, contraindication or intolerance to an angiotensin receptor blocker (ARB) (e.g., losartan)
History of suboptimal response (after a three-month trial), contraindication or intolerance to metformin (generic Glucophage, Glucophage XR)three-month trial
History of therapeutic failure (after a three-month trial), contraindication or intolerance to Jardiance

Invokamet, Invokamet XR, Xigduo XR, Segluromet

These combination agents will be approved when the following is met:

History of therapeutic failure (after a three-month trial), contraindication or intolerance to Synjardy/Synjardy XRthree-month trial

Applies to Invokamet, Invokamet XR, Xigduo XR, Segluromet

Inpefa (sotagliflozin)

Inpefa will be approved when the following is met:

History of therapeutic failure, contraindication or intolerance to a 30-day trial of Jardiance30-day trial

State mandates (e.g., Connecticut) may require only a 30-day trial

Other Agent-Specific Criteria & Indications

Glyxambi (empagliflozin/linagliptin) - other indications

Glyxambi will be approved when ONE of the following is met:

ANY of the following

History of suboptimal response (after a three-month trial), contraindication or intolerance to metformin (generic Glucophage, Glucophage XR)three-month trial
Currently on therapy with Glyxambi and is requesting continuation of the same therapy
Members with Glyxambi claim in prior 12 months allowed continuation

Automated continuation allowed based on claims history

Bexagliflozin (Brenzavvy authorized generic), Brenzavvy, Farxiga, Invokana, Steglatro

These agents will be approved when ALL of the following are met:

ALL of the following

History of suboptimal response (after a three-month trial), contraindication or intolerance to metformin (generic Glucophage, Glucophage XR)three-month trial
History of therapeutic failure (after a three-month trial), contraindication or intolerance to Jardiancethree-month trial

Applies to Bexagliflozin (Brenzavvy authorized generic), Brenzavvy, Farxiga, Invokana, Steglatro

Qtern or Steglujan

Qtern or Steglujan will be approved when ALL of the following are met:

ALL of the following

History of suboptimal response (after a three-month trial), contraindication or intolerance to metformin (generic Glucophage, Glucophage XR)three-month trial
History of therapeutic failure (after a three-month trial), contraindication or intolerance to Glyxambithree-month trial

Authorization typically issued for 12 months

Continuation Therapy Criteria

Continuation/renewal: Members currently on Glyxambi as documented in claims history will be allowed continued coverage and may be re-authorized via automated processes or claims lookback.

Authorization duration and re-authorization logic: Authorization is typically issued for 12 months. UnitedHealthcare may approve initial and re-authorization based solely on previous claim/medication history, diagnosis codes (ICD-10), and/or claim logic; automated approval and re-approval processes and claim-history lookback may be used.

Provider documentation: Providers must document history of therapeutic failure, contraindication, or intolerance to specified prior agents per the step criteria (for example, a 30-day Jardiance trial for certain heart failure/Inpefa criteria and three-month trials for other agents/steps).

Billing Rule

Automated continuation/lookback

Members currently on Glyxambi as documented in claims history will be allowed continued coverage of their current therapy. Prior claims/medication history may be used for automated approval or re-authorization.

Affected agent example: Glyxambi (empagliflozin/linagliptin)

Provider Actions & Prior Authorization

Prior Authorization

Prior authorization required

Prior Authorization/Medical Necessity may be required for SGLT2 inhibitors. Authorization decisions may be based on claims history, diagnosis codes (ICD-10), and claim logic. Authorizations are typically issued for 12 months.

Documentation Required

Document therapeutic failure/intolerance

Providers must document a history of therapeutic failure, contraindication, or intolerance to specified prior agents to meet step criteria. Required trial durations include a 30-day Jardiance trial for heart failure and for Inpefa, and three-month trials where specified for metformin, Jardiance, and Synjardy (as noted in the criteria).

Jardiance: 30-day trial required for heart failure and for Inpefa
Metformin/Jardiance/Synjardy: three-month trial required where specified in criteria

Clinical Evidence & Definitions

Background: SGLT2 inhibitors (including bexagliflozin/Brenzavvy, dapagliflozin/Farxiga, canagliflozin/Invokana, empagliflozin/Jardiance, ertugliflozin/Steglatro and others) are indicated as adjuncts to diet and exercise to improve glycemic control in adults with type 2 diabetes. Some agents (e.g., Farxiga, Invokana, Jardiance, Inpefa) have additional indications to reduce risk of heart-failure-related outcomes and/or to slow progression of chronic kidney disease.

Combination products: Several combination products are included in the program (SGLT2 + metformin such as Invokamet, Invokamet XR, Synjardy, Segluromet, Xigduo XR; and SGLT2 + DPP-4 such as Glyxambi, Qtern, Steglujan).

State mandate note: State mandates (for example, Connecticut) may modify required trial durations (the program notes that for Connecticut a 30-day trial may be required).

Definitions: Therapeutic failure / suboptimal response — policy language uses 'history of therapeutic failure' or 'suboptimal response' typically after defined trial durations (30 days for Jardiance in some indications; three-month trial for others).

Evidence and change log

P&T approval dates7/2023, 7/2024, 7/2025

Recent additions notedBrenzavvy (bexagliflozin) added July 2023; Inpefa (sotagliflozin) added July 2024

2025 updates / clarificationsJuly 2025 updates included annual review, updated excluded products and clarified authorized_generic labeling for bexagliflozin

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization/Medical Necessity Custom Oxford SoNY and SoCT SGLT2 Inhibitors

Policy CodePolicy P 2247-19

Change TypeAnnual review; added Brenzavvy and Inpefa; clarified authorized_generic labeling

Effective DateOct 12, 2025

Next Review Date

On This Page

OpenPayer

Prior Authorization/Medical Necessity Custom Oxford SoNY and SoCT SGLT2 Inhibitors

Coverage Summary

Initial Therapy Criteria

Other Agent-Specific Criteria & Indications

Continuation Therapy Criteria

Provider Actions & Prior Authorization

Applicable Medications / Codes Referenced

Clinical Evidence & Definitions

Revision History

Brenzavvy	bexagliflozin (authorized generic)
Bexagliflozin	Brenzavvy authorized generic
Brenzavvy (bexagliflozin)	brand/generic name
Farxiga	dapagliflozin
Invokana	canagliflozin
Invokamet	canagliflozin/metformin
Invokamet XR	canagliflozin/metformin extended-release
Glyxambi	empagliflozin/linagliptin
Inpefa	sotagliflozin
Jardiance	empagliflozin