Blog

Why Medicare Needs Prior Authorization for Jardiance?

If you’re a healthcare provider working with Medicare patients, you’re probably familiar with the hurdles that come up around prior authorizations. When it comes to medications like Jardiance—commonly prescribed for managing Type 2 diabetes and reducing cardiovascular risk—prior authorization can be one of those critical hoops to jump through. It’s a high-cost, specialized medication, so Medicare often requires providers to demonstrate medical necessity and proper fit for the patient’s condition. Here, we’ll break down exactly what you need to know to secure prior authorization for Jardiance under Medicare, from start to finish.

Insurance Company Overview

Medicare Part D is a part of Medicare that covers prescription medications, and if a patient has Medicare coverage, they are likely enrolled in a Part D plan. Part D plans are run by private insurers approved by Medicare, with each plan having its own formulary. Some drugs, especially high-cost or specialized ones like Jardiance, often require prior authorization. The purpose of requiring prior authorization is to ensure the medication is medically necessary and cost-effective. Medicare wants to confirm that Jardiance is the most appropriate treatment for the patient’s specific condition before covering the cost. Prior authorization is a way to ensure resources are allocated efficiently, especially for expensive drugs like Jardiance.

Why Jardiance Needs Prior Authorization Under Medicare?

Jardiance (empagliflozin) is typically prescribed to help manage blood sugar levels in patients with Type 2 diabetes, and it’s also been shown to reduce the risk of cardiovascular events in certain patients. Given its significant impact on both diabetes management and heart health, Jardiance can be a game-changer for many patients. However, it’s not a one-size-fits-all medication, and Medicare wants to verify that it’s truly necessary for each patient.

Because of its high cost and the specific conditions it treats, Medicare Part D plans often list Jardiance as a “Tier 3” or “Tier 4” drug—these are the higher tiers, which generally come with higher copays and, frequently, a prior authorization requirement. This prior authorization is essentially Medicare’s way of asking providers to validate that:

1. The patient has a qualifying diagnosis, such as Type 2 diabetes or heart failure.
2. Other treatment options have been considered or tried.
3. Jardiance is being prescribed in line with best practices and guidelines.

When you understand these underlying reasons, the prior authorization process may seem a bit more manageable. Now, let’s walk through the steps of actually securing this authorization under Medicare.

Step-by-Step Guide for Securing Prior Authorization for Jardiance Under Medicare

Here’s a practical, step-by-step guide to help you get Jardiance covered for your Medicare patients. Each part of this process will be familiar if you’ve gone through prior authorizations before, but knowing the specific details for Jardiance under Medicare can help you avoid some common pitfalls.

Step 1: Initial Prescription and Documentation

The first step is getting the prescription and gathering any documentation that supports the medical necessity of Jardiance for your patient. Start by obtaining a prescription from the treating physician. You’ll also want to compile the patient’s relevant medical records, including:

• Diagnosis and ICD-10 codes (e.g., E11.9 for Type 2 diabetes without complications or I50.9 for heart failure).
• Lab results and relevant clinical data (such as HbA1c levels for diabetes control).
• Previous medications tried and documented treatment history, especially if other diabetes medications have been less effective.

Detailed documentation can make a significant difference in the approval process. If you can show that alternative treatments were insufficient or caused adverse effects, Medicare is more likely to see Jardiance as a medically necessary next step.

Step 2: Submitting the Prior Authorization Request

Once you have the documentation in order, it’s time to submit the prior authorization request. Medicare Part D plans have their own systems for handling these requests, so the submission method can vary based on the plan your patient has. Generally, you’ll have two main options:

1. Online Submission: Many Medicare Part D insurers have online portals where you can submit prior authorization requests electronically. This can be a quicker and more reliable method, with an option to track the status of the request.
2. Fax or Email: If the insurer doesn’t offer an online portal, faxing or emailing the request is the alternative. Be sure to use the correct forms and include all necessary documentation to avoid delays.

If your patient is enrolled in a Medicare Advantage plan that includes Part D coverage, the submission process might differ slightly, as some Medicare Advantage plans have their own protocols. Double-checking with the plan provider can save time and prevent the request from being held up due to missing information.

Step 3: Completing Required Forms and Attaching Supporting Documents

Medicare typically requires a Statement of Medical Necessity, which is a form where the provider outlines the specific reasons why Jardiance is the best choice for the patient. This statement should emphasize:

• The patient’s medical condition and how Jardiance addresses it effectively.
• Any previous medications tried and why they were insufficient.
• The expected health benefits of using Jardiance based on the patient’s history.

Attach all relevant supporting documents, such as medical records, lab results, and clinical notes. The more comprehensive the documentation, the better. Medicare reviewers are looking for a clear, logical narrative that justifies the need for Jardiance, so each piece of evidence helps.

Step 4: Awaiting the Decision

After submitting the request, Medicare Part D plans typically respond within a few days to a week for non-urgent requests. If the patient’s condition requires expedited treatment, there’s an option to request a fast-track review, which Medicare aims to complete within 24 to 72 hours.

During this waiting period, it’s crucial to monitor the request’s status. Most plans offer ways to follow up either online or by phone, and it’s a good idea to check in if you haven’t heard back after a week. Delays can sometimes happen, and proactive follow-up helps ensure nothing slips through the cracks.

Step 5: Handling Approval or Denial

Once you receive Medicare’s decision, you’ll either get the green light to proceed with the Jardiance prescription or face a denial. Here’s what to do in each case:

• If Approved: Once approved, you can go ahead with filling the prescription under Medicare’s coverage. Be sure to confirm with the pharmacy that the patient’s copay aligns with their Part D plan’s formulary guidelines. Some providers even recommend double-checking the authorization period, as some approvals are time-limited and may require renewal after a few months.
• If Denied: If the request is denied, don’t lose hope. Medicare provides an appeals process for denied prior authorizations. Review the denial letter carefully, as it will usually list the specific reasons for the decision. Often, denials are due to missing information or insufficient documentation, which can be corrected in an appeal. Gather any additional data needed, and submit an appeal through the plan’s process, highlighting why Jardiance is medically necessary for the patient’s condition.

ICD and CPT Codes Explained

Accurate coding is essential for Medicare prior authorization. For Jardiance, you’ll generally use ICD-10 codes related to the conditions it’s meant to treat. Here are some typical examples:

• E11.9: Type 2 diabetes mellitus without complications
• E11.65: Type 2 diabetes mellitus with hyperglycemia
• I50.9: Heart failure, unspecified

The CPT codes may vary depending on the services provided during the patient’s consultation or assessment, but they’re generally linked to the clinical evaluation and management (E/M) services.

Frequently Asked Questions (FAQs)

Why does Medicare require prior authorization for Jardiance? Medicare requires prior authorization for high-cost drugs like Jardiance to ensure medical necessity. This helps Medicare manage costs while providing appropriate medications for patients who truly need them.

What if my prior authorization request for Jardiance is denied? If the initial request is denied, you can appeal the decision by providing additional supporting documentation or clarification on the medical necessity. Medicare’s appeals process is in place to ensure that providers can make a strong case for coverage if needed.

How often do I need to renew the prior authorization for Jardiance? Some approvals are valid for several months to a year, but this varies by plan. Always check the authorization’s duration and set reminders for renewals if needed.

Is there financial assistance if Medicare denies Jardiance authorization? Yes, several programs offer financial assistance for medications. Patients can explore options like pharmaceutical assistance programs through the drug manufacturer or third-party nonprofit organizations.

What Did We Learn?

Securing prior authorization for Jardiance under Medicare involves multiple steps, but thorough documentation and understanding Medicare’s specific requirements can help streamline the process. Gathering complete records, choosing the right submission method, and staying on top of any follow-ups or appeals can make a big difference in getting approval.

If all this feels overwhelming, you’re not alone—and you don’t have to go it alone. Staffingly, Inc. specializes in assisting healthcare providers with the ins and outs of prior authorizations, insurance verifications, and more. By outsourcing these tasks to Staffingly, you can save up to 70% on staffing costs, freeing up your team to focus on patient care while we handle the administrative legwork.

Disclaimer

The information in our posts is meant to inform and educate both healthcare providers and readers seeking a better understanding of the prior authorization process. However, it is not a substitute for professional advice. Insurance requirements, policies, and approval processes can vary widely and change over time. For accurate guidance, healthcare providers should consult directly with insurers or use professional resources, while patients should reach out to their insurance providers or healthcare professionals for advice specific to their situation.

This content does not establish any patient-caregiver or client-service relationship. Staffingly, Inc. assumes no liability for actions taken based on information provided in these posts.

For tailored support and professional services,

please contact Staffingly, Inc. at (800) 489-5877

Email : support@staffingly.com