Medicare covers Jardiance, but the amount you pay depends on which Medicare plan you have and which pharmacy you use

Jardiance (empagliflozin) is a diabetes medication that helps lower blood sugar in people with type 2 diabetes. Medicare Part D plans cover Jardiance, but it is not free. You will pay a copay or coinsurance amount that varies by plan. Some plans require you to try other diabetes drugs first before covering Jardiance, a step called a prior authorization. The actual cost depends on whether you have Original Medicare with a Part D plan, a Medicare Advantage plan, or no drug coverage at all.

Key Takeaways

  • Medicare Part D covers Jardiance as a prescription drug, but your out-of-pocket cost depends on your specific plan and pharmacy.
  • Your plan may require prior authorization, meaning your doctor must request approval before the pharmacy will fill the prescription.
  • Jardiance is usually placed on a higher cost tier (tier 3 or 4), so your copay or coinsurance will be higher than for generic diabetes drugs.
  • If you have Original Medicare without Part D, you pay the full price of Jardiance unless you join a Part D plan or a Medicare Advantage plan with drug coverage.
  • Manufacturer coupons and patient information programs can lower your cost, but you must check them against your plan's coverage rules first.

How Medicare Part D covers Jardiance

Medicare Part D is the prescription drug coverage you can add to Original Medicare, or that comes built into most Medicare Advantage plans. Part D plans maintain a list called a formulary that shows which drugs they cover and at what cost tier. Jardiance appears on the formularies of most major Part D plans, but not all of them.

When Jardiance is covered, it is usually placed on tier 3 or tier 4 of the formulary. Tier 1 drugs (generics) have the lowest copay. Tier 2 drugs (preferred brand-name) cost more. Tier 3 and tier 4 drugs cost the most — you might pay $35 to $75 per month or more, depending on your plan. Some plans use coinsurance instead of a copay, meaning you pay a percentage of the drug's cost (often 25% to 33%) rather than a flat amount.

Prior authorization and step therapy requirements

Many Medicare Part D plans require prior authorization before they will cover Jardiance. This means your doctor must submit a request to the plan explaining why you need this specific drug. The plan reviews the request and either approves it or denies it. If approved, you can fill the prescription. If denied, your doctor can appeal or prescribe a different drug.

Some plans also use step therapy, which means you must try and fail on a cheaper drug first — often metformin or another generic diabetes medication — before the plan will cover Jardiance. Step therapy can delay your treatment by weeks or months. Ask your doctor or call your plan to find out whether your specific plan requires prior authorization or step therapy for Jardiance before your doctor writes the prescription.

What to do if your plan does not cover Jardiance

If your Part D plan's formulary does not include Jardiance, or if the cost tier is too high, you have several options. First, ask your doctor whether a different diabetes drug on your plan's formulary might work for you. Generic metformin, SGLT2 inhibitors like canagliflozin (Invokana), or GLP-1 drugs like semaglutide may be covered at a lower cost.

Second, you can request a formulary exception from your plan. Your doctor submits a letter explaining why Jardiance is medically necessary for you and why other covered drugs will not work. The plan has 72 hours to respond. If approved, the plan will cover Jardiance, often at a reduced cost tier. If denied, your doctor can appeal to an independent review organization.

Third, you can switch to a different Part D plan during the annual enrollment period (October 15 to December 7 each year) if another plan covers Jardiance at a lower cost. Use the Medicare Plan Finder tool on Medicare.gov to compare plans and their formularies side by side.

Medicare Advantage plans and Jardiance coverage

Medicare Advantage plans (Part C) include drug coverage as part of the plan. Most Medicare Advantage plans cover Jardiance, but the cost and prior authorization rules vary by plan and by region. Some Medicare Advantage plans have lower copays for Jardiance than standalone Part D plans, while others have higher ones.

If you are in a Medicare Advantage plan and Jardiance is not covered or is too expensive, the same options explore: ask about formulary exceptions, request step therapy appeals, or switch to a different Medicare Advantage plan during open enrollment. You can also switch from Medicare Advantage back to Original Medicare with a Part D plan if you find better coverage that way.

Using manufacturer coupons and patient information programs

Boehringer Ingelheim, the manufacturer of Jardiance, offers a patient information program that can reduce your copay to as low as $0 to $15 per month, depending on your income and insurance status. You can learn about this program by calling 1-855-354-7378 or visiting the Jardiance website.

Before using a manufacturer coupon or information program, check with your Part D plan first. Some plans do not allow you to use manufacturer coupons because it interferes with how the plan tracks your costs toward the deductible and out-of-pocket maximum. Your pharmacist can tell you whether your plan permits it. If your plan does allow it, the coupon can save you hundreds of dollars per year.

Costs after you reach your out-of-pocket maximum

Every Medicare Part D plan has an annual out-of-pocket maximum. Once you and your plan have paid a certain amount toward your prescriptions in a calendar year, your coverage changes. For 2024, the maximum is $7,050, though this amount increases each year. After you reach this maximum, you pay only a small copay (usually $3 to $5) for all remaining prescriptions for the rest of that calendar year.

If you take Jardiance year-round at a high copay, you may reach your out-of-pocket maximum by mid-year. Once you do, your Jardiance copay drops dramatically. Keep track of your spending throughout the year so you know when you will reach this point.

Questions to ask your doctor and plan

Before your doctor prescribes Jardiance, ask these questions: Does my Part D plan cover Jardiance, and at what cost tier? Does my plan require prior authorization or step therapy? If Jardiance is not covered, can my doctor request a formulary exception? Are there other diabetes drugs on my plan's formulary that might work for me?

Call your Part D plan's customer service number (on the back of your insurance card) and ask: Is Jardiance on my formulary? What is my copay or coinsurance? Do I need prior authorization? Can I use a manufacturer coupon? Your plan can answer these questions in minutes and save you from surprises at the pharmacy.

Frequently Asked Questions

Does Original Medicare Part A or Part B cover Jardiance?

No. Part A covers hospital care and Part B covers doctor visits and outpatient services. Prescription drugs are covered only by Part D (or by a Medicare Advantage plan that includes drug coverage). If you have Original Medicare without Part D, you pay the full price of Jardiance out of pocket.

Can I use a GoodRx coupon instead of my Medicare plan?

You can, but it may not save you money. GoodRx coupons are often cheaper than Medicare copays for brand-name drugs, but using them means the cost does not count toward your Part D deductible or out-of-pocket maximum. If you are close to reaching your out-of-pocket maximum, paying your regular copay may be smarter in the long run. Compare the GoodRx price to your copay before deciding.

What if my doctor prescribes Jardiance but my plan denies prior authorization?

Your doctor can appeal the denial to your plan, or request a formulary exception. You can also file a complaint with Medicare by calling 1-800-MEDICARE. If the appeal is denied, your doctor can prescribe a different covered drug, or you can pay out of pocket for Jardiance while pursuing the appeal.

Will my Jardiance copay change if I switch Medicare plans?

Yes. Each plan sets its own formulary and cost tiers. A plan that charges $50 per month for Jardiance might be different from another plan that charges $30. During open enrollment, compare the Jardiance copay across plans using the Medicare Plan Finder tool before you switch.

Does Medicare cover Jardiance for weight loss?

Medicare covers Jardiance only when it is prescribed for type 2 diabetes. If your doctor prescribes it for weight loss alone (off-label use), Medicare will not cover it, and you will pay the full price out of pocket. Talk to your doctor about whether Jardiance is appropriate for your specific condition.