SGLT2 inhibitor access landscape in 2026

Sodium-glucose cotransporter-2 (SGLT2) inhibitors have evolved beyond their initial type 2 diabetes indication to become foundational therapies for heart failure and chronic kidney disease. Six SGLT2 inhibitors are FDA-approved in the US: Jardiance (empagliflozin), Farxiga (dapagliflozin), Invokana (canagliflozin), Steglatro (ertugliflozin), Brenzavvy (bexagliflozin), and Inpefa (sotagliflozin). Both Jardiance and Farxiga are among the ten drugs with IRA-negotiated Medicare prices effective in 2026, and authorized generic dapagliflozin launched in January 2024.

This landscape guide is for prescribers, access teams, pharmacists, and payer professionals who need a cross-SGLT2 view of coverage, prior authorization, cost trends, and upcoming market changes.

FDA-approved SGLT2 inhibitors at a glance

Common FDA-approved indications

ACC/AHA guidelines recommend SGLT2 inhibitors (specifically Jardiance, Farxiga, or Inpefa) for all symptomatic chronic HFrEF patients to reduce heart failure hospitalization and cardiovascular death. Jardiance and Farxiga are recommended for all patients with symptomatic HFpEF. The combination of strong guideline support and multiple indications has made SGLT2 inhibitors one of the most widely prescribed cardiometabolic drug classes.

Formulary placement and prior authorization

SGLT2 inhibitors are among the most widely prescribed specialty-tier drugs in the US. Medicare plans are most likely to cover at least one SGLT2 inhibitor without prior authorization or step therapy (98% of covered lives), compared with 61% of commercial plans and 43% of Medicaid plans.

Commercial insurance

UHC's 2026 SGLT2 inhibitor policy is illustrative of the broader market:

• Jardiance: Preferred agent; typically Tier 2 without PA for T2D

• Farxiga, Inpefa: Require PA; Jardiance failure, contraindication, or intolerance documented before approval

• Brenzavvy, Invokana, Steglatro: Require PA; documented failure of both metformin (3-month trial) and Jardiance

• Combination products (Synjardy, Xigduo, Qtern, Segluromet, Glyxambi, Steglujan, Invokamet, Trijardy XR): Varying PA requirements

Key PA criteria patterns across payers:

1. Type 2 diabetes: Trial and failure of metformin (3-month trial at maximally tolerated dose) unless contraindicated. Jardiance is often preferred first-line SGLT2

2. Heart failure: Documented diagnosis (HFrEF, HFpEF). Some payers require Jardiance trial before Farxiga or Inpefa. For non-T2D HF indications, metformin prerequisite is typically waived

3. Chronic kidney disease: ACE inhibitor or ARB concurrent therapy required. Jardiance trial before Farxiga commonly required

4. Not used in combination with another SGLT2 inhibitor: Standard exclusion criterion

Medicare Part D

Both Jardiance and Farxiga are among the ten drugs with IRA-negotiated Medicare prices effective January 1, 2026:

Key Medicare access points:

• All Medicare Part D and Medicare Advantage drug plans must cover both Jardiance and Farxiga under the IRA requirement for negotiated drugs

• The Part D out-of-pocket cap is $2,100 in 2026

• Prior authorization may still apply but cannot result in coverage denial for FDA-approved indications of negotiated drugs

• SGLT2 inhibitors must remain covered on all formularies for the entire plan year, even though authorized generic dapagliflozin is available

• A CMS/HHS analysis found the negotiated prices represent 66-68% discounts from 2023 list prices, with projected Part D savings of $6 billion across all ten negotiated drugs in 2026

Medicaid

State Medicaid programs cover SGLT2 inhibitors with varying PA criteria. A JAMA-published analysis found:

• Medicaid plans were most likely to require prior authorization (48% of covered lives for empagliflozin)

• Medicaid plans were least likely to cover at least one SGLT2 without PA or step therapy (43% of covered lives)

• Step therapy through metformin is standard

• Some states are beginning to adopt preferred SGLT2 lists that may favor one agent based on rebate negotiations

Generic competition and pricing

Despite the authorized generic launch, Milliman's 2026 formulary analysis notes that Farxiga must remain covered on all Medicare formularies under the MDPNP requirement throughout 2026, even as generic dapagliflozin becomes available. Plans must carefully consider coverage strategies for brand Farxiga versus generic dapagliflozin at initial generic launch and once generics are widely available at lower prices.

Maryland's Prescription Drug Affordability Board is actively reviewing both Jardiance and Farxiga for Upper Payment Limits (UPLs), using the Medicare Maximum Fair Price as the methodology basis. This could create additional state-level pricing pressure in 2026-2027.

Prior authorization checklist

When submitting prior authorization for any SGLT2 inhibitor, prepare:

1. Diagnosis documentation: ICD-10 code (E11.x for T2D, I50.x for HF, N18.x for CKD)

2. Indication-specific criteria:

   • T2D: Document metformin trial and failure/intolerance (unless contraindicated)

   • HF: Document HF type (HFrEF/HFpEF), LVEF if available, and symptom status

   • CKD: Document eGFR staging, concurrent ACE inhibitor or ARB therapy

3. Preferred agent trial: Document Jardiance trial and failure/intolerance if payer requires Jardiance-first step therapy

4. Renal function: Current eGFR — critical for dose selection and eligibility

5. Concurrent medications: Note diuretics, insulin, or other antihyperglycemic agents

6. Contraindications check: Type 1 diabetes, diabetic ketoacidosis history, severe renal impairment below threshold

Common ICD-10 codes for SGLT2 inhibitor PA:

Cost and copay programs

Commercial copay programs

Patient assistance

AstraZeneca offers the AZ&Me patient assistance program for Farxiga: qualifying patients can receive free brand-name Farxiga for up to one year, with annual re-enrollment. Boehringer Ingelheim and Lilly offer a similar program for Jardiance.

WAC pricing context

With IRA-negotiated prices, the effective Medicare cost for Jardiance drops to ~$2,364/year and Farxiga to ~$2,142/year, representing 66-68% discounts from list prices.

Health equity and access disparities

A JAMA-published analysis of SGLT2 inhibitor coverage across US insurance plan types found significant disparities:

• Medicare plans were most likely to cover at least one SGLT2 inhibitor without PA or step therapy (98% of covered lives)

• Commercial plans covered at least one SGLT2 without restrictions for only 61% of covered lives

• Medicaid plans had the most restrictive access, with only 43% of covered lives having unrestricted access to at least one SGLT2

• Medicaid plans were most likely to require prior authorization (48% of covered lives for empagliflozin, 42% for dapagliflozin)

These disparities are clinically significant because SGLT2 inhibitors have strong guideline support for heart failure and CKD, conditions that disproportionately affect Black, Hispanic, and economically disadvantaged populations. Restrictive PA criteria in Medicaid may limit access for the patients who stand to benefit most from cardiorenal protection.

What to monitor next

• Generic dapagliflozin uptake (2026-2027): As the first generic SGLT2 inhibitor becomes more widely available, expect rapid formulary shifts. Payers may require generic dapagliflozin before branded Jardiance or Farxiga, particularly in commercial plans

• Maryland PDAB Upper Payment Limits: Active review of Jardiance and Farxiga for state-level UPLs could set a precedent for other states and create additional pricing pressure

• IRA second-round negotiations: CMS is negotiating prices for 15 additional drugs for 2027, including Ozempic, Rybelsus, and Wegovy. Cardiometabolic agents may appear in future cycles

• Inpefa market uptake: As the newest SGLT1/2 inhibitor with a dual mechanism, monitor payer adoption for heart failure and CKD indications

• Brenzavvy commercial trajectory: As a newer entrant with T2D-only indication, watch for payer positioning and any HF or CKD label expansion

• Formulary consolidation around Jardiance: Multiple payers are establishing Jardiance as the preferred SGLT2 agent, with step therapy required for alternatives. Monitor whether this pattern accelerates with IRA-negotiated pricing

• Combination product strategy: SGLT2/DPP-4 combinations (Glyxambi, Steglujan, Qtern) and SGLT2/metformin combinations (Synjardy, Xigduo) face uncertain formulary positioning as individual agents face pricing pressure

Disclaimer

This article is for informational purposes only and does not constitute medical advice. Coverage, formulary placement, and prior authorization criteria vary by plan and change frequently. Always verify current requirements with the patient's specific payer.

Sources

• CMS. Medicare Drug Price Negotiation Program: Selected Drugs for Initial Price Applicability Year 2026. https://www.cms.gov/files/document/fact-sheet-medicare-selected-drug-negotiation-list-ipay-2026.pdf

• ASPE/HHS. Medicare Prices Negotiated for 2026 Compared to List and US Net Prices. https://aspe.hhs.gov/reports/medicare-prices-negotiated-2026

• ASPE/HHS. Price Change Over Time for Selected Medicare Part D Drugs. https://aspe.hhs.gov/sites/default/files/documents/3e8abec86039ac0ed674a8c5fac492e3/price-change-over-time-brief.pdf

• UHC. Diabetes Medications — SGLT2 Inhibitors Coverage Criteria. https://www.uhcprovider.com/content/dam/provider/docs/public/resources/pharmacy/oxford/Diabetes-Medications-SGLT2-Inhibitors-Oxford.pdf

• CDPHP. 2026 Medicare Part D Step Therapy Drug List. https://www.cdphp.com/-/media/files/medicare/medicare2026/members/medicare-part-d-step-therapy-drug-list.pdf

• Premera. SGLT2 Inhibitors Medical Policy 5.01.646. https://www.premera.com/medicalpolicies/5.01.646.pdf

• PMC/JAMA. Coverage, Formulary Restrictions, and Affordability of SGLT2 Inhibitors by US Insurance Plan Types. https://pmc.ncbi.nlm.nih.gov/articles/PMC8796944

• Milliman. Prescribing a Part D Formulary for the New IRA World. https://www.milliman.com/en/insight/prescribing-part-d-formulary-new-ira

• Maryland PDAB. Jardiance Cost Review Study Report (March 2026). https://pdab.maryland.gov/Documents/Cost%20Review/2026/3.4.26%20Jardiance%20Methodology%20Comments%20%281%29.pdf

• Medicare Rights Center. Negotiated Prices Take Effect for Ten Drugs in 2026. https://www.medicarerights.org/medicare-watch/2025/10/09/negotiated-prices-take-effect-for-ten-drugs-in-2026

• Medicare Advocacy. Medicare Announces Results of First Round of Historic Drug Price Negotiations. https://medicareadvocacy.org/medicare-announces-results-of-first-round-of-historic-drug-price-negotiations-effective-2026

• SingleCare. Average Cost of Farxiga on Medicare. https://www.singlecare.com/blog/cost-of-farxiga-on-medicare

• HealthSpring. 2026 Drug List Formulary Updates. https://www.healthspring.com/providers/news/1-29-2026-drug-list-formulary

• diaTribe. Lower Prices Announced for Top Diabetes Drugs Covered by Medicare. https://diatribe.org/diabetes-medications/top-diabetes-drugs-get-lower-medicare-pricing