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HumanaMedicare Advantage · Prior Auth · Medicare Advantage · Endocrinology, Cardiology, Nephrology +3 moreHigh impact

Jardiance (empagliflozin) (New)

Act
by Jan 1, 2027
Effective date
Jan 1, 2027
Identified
Oct 2, 2026

Summary

Humana Medicare Advantage has implemented a new prior authorization policy for Jardiance (empagliflozin) effective January 1, 2027, covering three indications: Type 2 Diabetes Mellitus, Heart Failure, and Chronic Kidney Disease at Risk of Progression. All three indications require documented failure or inability to use generic dapagliflozin as a prerequisite, with specific exclusions including eGFR <30 for diabetes glycemic control, polycystic kidney disease for CKD, and certain immunosuppressive therapy use for CKD.

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What to do

by Jan 1, 2027 · 7 steps
01Billing and prior authorization teams must implement new workflow requiring prior authorization submission for all Jardiance prescriptions on Humana Medicare Advantage plans.
02Update authorization software to enforce three distinct approval pathways based on clinical indication (Type 2 Diabetes, Heart Failure, or CKD at Risk of Progression).
03For each authorization request, require documentation that the member has tried or cannot use generic dapagliflozin tablet before approval can be granted.
04For Type 2 Diabetes indication specifically, ensure eGFR is documented and flag for denial review if eGFR <30 mL/min/1.73 m².
05For CKD indication, add screening questions to deny if polycystic kidney disease is present or if member requires IV immunosuppressive therapy or >45 mg prednisone equivalent for kidney disease.
06Update provider-facing materials and prior auth request forms to clearly state dapagliflozin failure requirement and indication-specific exclusions.
07Train billing staff and prior authorization specialists on the three separate approval pathways and exclusion criteria.
If missed: Failure to obtain prior authorization will result in claim denials; claims submitted without prior auth documentation will be rejected at point of service.

Original notice

Jardiance (empagliflozin) (New)
mcp.humana.com · Always check the source before changing claims.
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Humana policiesEndocrinologyCardiologyNephrologyInternal MedicineFamily MedicineGeriatrics

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