Medicare Part D covers Jardiance, but only if your specific plan includes it
Jardiance (empagliflozin) is a diabetes medication that many Medicare Part D plans do cover, but coverage is not automatic. Whether your plan pays for it depends on three things: which plan you're in, whether Jardiance is on that plan's formulary (the list of covered drugs), and whether your doctor has met any prior approval requirements the plan has set. The fastest way to know for certain is to check your plan's formulary document or call the plan directly — not your pharmacy, and not your doctor's office.
If your plan does not cover Jardiance, you have options: you can switch to a different Part D plan during the annual enrollment period, ask your doctor about alternative diabetes medications your plan does cover, or request that your plan make an exception. None of these routes is automatic, and timing matters.
Key Takeaways
- Your Part D plan's formulary lists which drugs it covers; Jardiance appears on most formularies but not all, and coverage rules change each year.
- Call your plan's customer service number (on your insurance card) to confirm Jardiance coverage before filling a prescription, because pharmacy staff cannot always see Part D details.
- If your plan does not cover Jardiance, you can request a coverage exception, switch plans during open enrollment, or ask your doctor about covered alternatives.
- Some plans cover Jardiance only after you have tried and failed on a cheaper diabetes drug first — a requirement called step therapy.
- Your out-of-pocket cost for Jardiance varies by plan and by which coverage stage you are in (deductible, copay, or catastrophic).
How to check your plan's formulary for Jardiance
Every Medicare Part D plan publishes a formulary — a list of medications it covers and the cost tier for each. Jardiance usually appears on the formulary of most major plans, but not all, and the tier (which determines your copay) varies. You can find your plan's formulary three ways: online through your plan's website, by calling the customer service number on your insurance card, or by visiting Medicare.gov and using the Plan Finder tool.
When you call your plan, have your member ID ready and ask specifically whether Jardiance is covered, what tier it is on, and whether your doctor needs to submit a prior authorization request. Do not ask your pharmacy — they see retail prices, not Part D coverage details, and will often give you incorrect information. Do not assume your doctor's office knows; they prescribe the drug but do not manage your insurance coverage.
If you use Medicare.gov's Plan Finder, enter your zip code, select your current plan, and search for "empagliflozin" or "Jardiance" by brand name. The tool will show you the tier and any restrictions. Write down the plan's phone number and the formulary year — formularies change every January, so if you are checking in June, you are looking at the current year's rules.
What tier Jardiance is on and what you will pay
Medicare Part D divides drugs into tiers, usually four or five. Tier 1 drugs (generics) cost the least; Tier 2 (preferred brand-name) and Tier 3 (non-preferred brand-name) cost more; Tier 4 and 5 are specialty drugs and biologics. Jardiance is a brand-name drug, so it typically lands on Tier 2 or Tier 3, depending on the plan. Some plans have negotiated lower costs for it; others have not.
Your actual copay also depends on which coverage stage you are in. In 2024, if you have not yet met your deductible, you pay the full price until you do. Once you hit the deductible, you pay a copay (usually $35 to $75 for a Tier 2 drug, more for Tier 3). After you and your plan have spent a combined $7,050 out of pocket, you enter catastrophic coverage and pay a small copay again. These numbers change yearly, so confirm the current amounts with your plan.
If the copay is too high, ask your plan whether a generic alternative is available. Empagliflozin (the generic version of Jardiance) may be on a lower tier and cost less. Your doctor can prescribe it by generic name.
Prior authorization and step therapy requirements
Some Medicare Part D plans require prior authorization before they will cover Jardiance. This means your doctor must submit a form to the plan explaining why you need this drug, and the plan must approve it before you fill the prescription. This is not a denial — it is a verification step that usually takes one to three business days. Your doctor's office typically handles this, but confirm they know to submit it before you go to the pharmacy.
Other plans use step therapy, which means you must try a cheaper diabetes drug first (often metformin or a sulfonylurea) and show that it did not work or caused side effects before the plan will cover Jardiance. If your plan has step therapy and you have already tried those drugs, your doctor can document that and request an exception. This takes longer — usually five to ten business days — so plan ahead if you are starting a new prescription.
Ask your plan directly whether Jardiance requires prior authorization or step therapy. If it does, ask what documentation your doctor needs to provide. Having this information before your doctor writes the prescription saves time and frustration at the pharmacy.
What to do if your plan does not cover Jardiance
If your plan's formulary does not include Jardiance, you have three paths forward. The first is to request a coverage exception, also called a formulary exception. Your doctor submits a letter to your plan explaining why Jardiance is medically necessary for you — for example, because you have tried other drugs and they did not work, or because you have a condition that makes Jardiance the right choice. The plan has 72 hours to respond (or longer if you ask for an expedited review). Some plans approve these; others deny them. There is no cost to request one.
The second path is to switch to a different Part D plan. You can do this during the annual enrollment period (October 15 to December 7 each year) or if you may have access to for a special enrollment period (such as moving to a new state or losing other coverage). Use Medicare.gov's Plan Finder to search for plans that cover Jardiance in your area. Compare the premiums, deductibles, and copays — a plan with lower Jardiance costs might have a higher premium, so calculate the total cost for your situation.
The third path is to work with your doctor to switch to a different diabetes medication that your plan does cover. This is not ideal if Jardiance is the right drug for you, but it may be necessary. Ask your doctor whether a covered alternative would work for your health needs.
How to request a coverage exception
A coverage exception (or formulary exception) is a formal request to your plan asking it to cover a drug that is not on its formulary or to waive a restriction like step therapy. Your doctor must submit the request on your behalf — you cannot do it yourself. Here is the process:
- Call your plan and ask for the coverage exception form and the fax number or address where your doctor should send it.
- Give your doctor the form and ask them to write a letter explaining why Jardiance is medically necessary for you. They should mention any other drugs you have tried and why they did not work, or why Jardiance is the best choice for your condition.
- Your doctor's office faxes or mails the form and letter to your plan.
- Your plan reviews it and sends you a decision, usually within 72 hours. If you request expedited review (because you need the drug urgently), they must respond within 24 hours.
- If the plan denies the exception, you can appeal. Ask your plan for the appeal process and important date.
Keep copies of everything you submit. If the plan denies your request, you will need those documents for an appeal.
Switching Part D plans to get Jardiance coverage
If your current plan does not cover Jardiance and a coverage exception is not approved, switching plans is often the most straightforward option. You can change Part D plans once per year during the annual enrollment period (October 15 to December 7). If you have a may have access to life event — such as moving, losing other insurance, or turning 65 — you may be able to switch outside this window.
To find a plan that covers Jardiance, go to Medicare.gov, click "Plan Finder," enter your zip code and current medications (including Jardiance), and the tool will show you plans that cover it. Compare the monthly premium, annual deductible, copay for Jardiance, and your total estimated out-of-pocket cost for the year. A plan with a higher premium might have a lower copay for Jardiance, making it cheaper overall.
Once you choose a new plan, you can enroll online at Medicare.gov, by phone at 1-800-MEDICARE, or through your plan's website. Your new coverage starts January 1 of the following year. Your current plan ends December 31. During the transition, ask your current plan whether they will fill a 30-day supply of Jardiance to bridge the gap, or ask your doctor for samples.
Generic empagliflozin as a lower-cost alternative
Empagliflozin is the generic version of Jardiance and is covered by most Medicare Part D plans on a lower tier than the brand name. If your plan covers the generic but not the brand, ask your doctor to prescribe "empagliflozin" instead of "Jardiance." The medication is identical; the only difference is the price you pay.
Some pharmacies will automatically substitute the generic if your prescription says "Jardiance" — this is called generic substitution — but not all states allow it without your doctor's permission. Call your pharmacy and ask whether they will substitute, or call your doctor and ask them to write the prescription for empagliflozin by name. Either way, the copay should be lower.
Frequently Asked Questions
Does Medicare Part D always cover Jardiance?
No. Most major Part D plans cover Jardiance, but not all, and coverage rules change every January. Check your specific plan's formulary or call your plan's customer service number to confirm. Do not assume it is covered just because it is a common diabetes drug.
What if I cannot afford the copay for Jardiance?
Ask your doctor whether the generic empagliflozin is available and covered at a lower tier. If the copay is still too high, ask your plan about patient information programs or contact the drug manufacturer (Boehringer Ingelheim) directly — they sometimes offer copay cards or free medication programs for people who meet income requirements.
How long does a coverage exception take?
Your plan must respond within 72 hours of receiving your doctor's request. If you ask for expedited review (because you need the drug urgently), they must respond within 24 hours. Ask your plan which option applies to your situation.
Can I appeal if my plan denies coverage?
Yes. Your plan must send you information about how to appeal when they deny your coverage exception request. You have a time limit to appeal (usually 60 days), so act quickly. Your doctor can submit additional information to support the appeal.
What happens to my Jardiance prescription if I switch Part D plans?
Your old plan ends December 31 and your new plan starts January 1. Ask your current plan whether they will fill a 30-day supply to cover the gap, or ask your doctor for samples. Your new plan's formulary and copay will explore starting January 1.