Does Blue Cross Blue Shield of Arizona Cover Jardiance?

What Is Jardiance and Why Does Coverage Matter?

Jardiance is the brand name for empagliflozin, a sodium-glucose cotransporter-2 (SGLT2) inhibitor approved by the FDA for three distinct indications. The FDA approved empagliflozin for glycemic control in type 2 diabetes in August 2014, for cardiovascular risk reduction in adults with type 2 diabetes and established cardiovascular disease in December 2016, and for reducing the risk of cardiovascular death and hospitalization in adults with heart failure with reduced ejection fraction (HFrEF) in August 2021 (FDA label, accessdata.fda.gov).

Clinical Evidence That Drives Prescribing

The EMPA-REG OUTCOME trial (N=7,020) demonstrated that empagliflozin 10 mg or 25 mg reduced the composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke by 14% relative to placebo (hazard ratio 0.86, 95% CI 0.74 to 0.99, P<0.001 for non-inferiority; P=0.04 for superiority) in adults with type 2 diabetes and high cardiovascular risk (Zinman B et al., NEJM, 2015). Cardiovascular death alone was reduced by 38%.

The EMPEROR-Reduced trial (N=3,730) showed empagliflozin 10 mg reduced the risk of cardiovascular death or hospitalization for heart failure by 25% versus placebo (hazard ratio 0.75, 95% CI 0.65 to 0.86, P<0.001) in patients with HFrEF (Packer M et al., NEJM, 2020).

These trial results directly influence why payers like BCBSAZ require prior authorization. Insurers use clinical evidence to define "medically appropriate" use, and Jardiance's multiple approved indications mean each indication may have slightly different prior authorization criteria.

Why SGLT2 Inhibitor Coverage Is Complicated

SGLT2 inhibitors as a class, including Jardiance, dapagliflozin (Farxiga), and canagliflozin (Invokana), compete for the same formulary slots. BCBSAZ, like most large payers, designates one or two preferred SGLT2 inhibitors per formulary year. The preferred agent gets placed on a lower tier with fewer utilization management hurdles. Jardiance may be preferred on some BCBSAZ plan types and non-preferred on others, which is why calling the member services number on the back of your card (or logging into your BCBSAZ online member portal) is the only definitive way to check your specific plan's current formulary status.

How BCBSAZ Formularies Are Structured

Blue Cross Blue Shield of Arizona uses a tiered formulary system across its commercial, Medicare Advantage (available through its AZ Blue Medicare portfolio), and Marketplace plans. Understanding this structure helps predict your likely out-of-pocket cost.

Tier Definitions for BCBSAZ Commercial Plans

Most BCBSAZ commercial plans use a four-to-five tier structure:

• Tier 1: Generic drugs. Lowest copay, typically $5, $15 per 30-day supply.
• Tier 2: Preferred brand drugs. Copays typically $35, $55 per 30-day supply.
• Tier 3: Non-preferred brand drugs. Copays typically $60, $100 per 30-day supply.
• Tier 4: Specialty drugs (on some plan designs). Coinsurance of 20 to 33% with no cap until out-of-pocket maximum is met.

Jardiance most commonly appears at Tier 3 on BCBSAZ commercial plans, though employer-sponsored plan administrators have discretion to negotiate different formulary arrangements. Some large employer groups in Arizona have negotiated Jardiance to Tier 2 as a preferred SGLT2 agent.

Medicare Advantage and Part D Formularies

For BCBSAZ Medicare Advantage members, Jardiance formulary placement follows CMS Part D formulary rules. The CMS 2024 Medicare Prescription Drug Plan formulary data shows empagliflozin appearing across Part D plans at varying tiers (CMS.gov, Medicare Plan Finder). On BCBSAZ Medicare Advantage plans specifically, you must consult the plan's Annual Notice of Change (ANOC) or Evidence of Coverage (EOC) document for each benefit year, because formulary tier placements can shift annually.

One practical point: the Boehringer Ingelheim manufacturer savings card for Jardiance explicitly excludes Medicare and Medicaid beneficiaries. If you are on a BCBSAZ Medicare Advantage plan, that savings card is not available to you, and your cost is solely determined by your plan's cost-sharing structure.

Marketplace (ACA) Plans Through BCBSAZ

BCBSAZ offers Marketplace plans under the Blue Cross Blue Shield of Arizona name on the HealthCare.gov exchange. These plans must cover prescription drugs as an essential health benefit under the ACA (HHS.gov, ACA essential health benefits). However, which specific drugs appear on the formulary and at what tier varies by metal level (Bronze, Silver, Gold) and plan design. Bronze plans tend to carry higher cost-sharing for brand-name drugs like Jardiance.

Prior Authorization Requirements for Jardiance Through BCBSAZ

Prior authorization (PA) is required for Jardiance on the majority of BCBSAZ plan types. This is consistent with industry-wide practice for brand-name SGLT2 inhibitors.

Typical PA Criteria BCBSAZ Applies

While exact criteria vary by plan year and plan type, BCBSAZ prior authorization for Jardiance commonly requires the prescribing physician to document:

1. A confirmed diagnosis of type 2 diabetes (ICD-10: E11.x), heart failure with reduced ejection fraction (ICD-10: I50.2x), or chronic kidney disease (ICD-10: N18.x) depending on the indication being authorized.
2. For type 2 diabetes indications: documentation that the patient has tried metformin (first-line therapy per the American Diabetes Association Standards of Care) and either a clinical reason for preferring an SGLT2 inhibitor over other agents or an established cardiovascular disease or CKD comorbidity that supports guideline-directed prescribing.
3. Current HbA1c level and/or relevant cardiac or renal function data (eGFR, echocardiographic LVEF for HFrEF indication).
4. Prescriber attestation that the drug is being used within FDA-approved labeling.

The American Diabetes Association 2024 Standards of Care state: "For patients with type 2 diabetes and established cardiovascular disease, heart failure, or chronic kidney disease, an SGLT2 inhibitor or GLP-1 receptor agonist with demonstrated cardiovascular benefit is recommended regardless of HbA1c or individualized HbA1c target" (ADA Standards of Care 2024, Diabetes Care). This ADA guidance strengthens PA approval arguments when the prescriber documents a qualifying cardiovascular or renal comorbidity.

How Long PA Takes and What Happens If It Is Denied

BCBSAZ is required under Arizona state law (ARS Title 20, Chapter 4) and ACA regulations to process standard PA requests within 72 hours and urgent PA requests within 24 hours. If a PA is denied, you receive a written Explanation of Benefits (EOB) specifying the denial reason. From that date, you have the right to:

• Request an internal appeal (first level) within 180 days of the denial notice.
• Request a second-level internal appeal if the first is denied.
• Request an Independent Medical Review (external review) through the Arizona Department of Insurance and Financial Institutions if both internal levels are exhausted.

Your prescribing physician can submit clinical notes, published guidelines (such as the ADA 2024 Standards of Care), and trial data (such as EMPA-REG OUTCOME results) as supporting documentation during the appeal process. Appeals that cite specific guideline language have a meaningfully higher success rate than bare clinical assertions.

What Jardiance Costs With and Without BCBSAZ Coverage

The list price (WAC) for Jardiance is approximately $622 per 30-day supply as of early 2025 without any insurance or discount. BCBSAZ coverage substantially reduces this, but your net cost still depends on whether you have met your deductible.

Before Your Deductible Is Met

If you are in the deductible phase of your plan year, you pay the plan's contracted (negotiated) rate rather than the full WAC. BCBSAZ's negotiated rate for Jardiance is not publicly disclosed, but contracted rates for brand-name drugs typically run 15 to 35% below WAC through a pharmacy benefit manager. That means you might pay $400, $530 per 30-day supply before your deductible is satisfied.

After Your Deductible Is Met

Once your deductible is met, you pay only the plan's cost-sharing amount. At Tier 3 with a $75 copay, your monthly cost drops to $75. At Tier 3 with coinsurance (say 25%), your cost would be roughly $155 per month based on the contracted rate. Check your Summary of Benefits and Coverage (SBC) document, which BCBSAZ is legally required to provide, for your specific cost-sharing amounts.

Manufacturer Savings Card

Boehringer Ingelheim and Eli Lilly (Jardiance co-developers) offer a savings card at the Jardiance website that may reduce out-of-pocket costs to as low as $10 per month for eligible commercially insured patients. Eligibility requires that the patient is covered by commercial insurance (including employer-sponsored and Marketplace plans through BCBSAZ) and is not enrolled in any federal or state government-funded program including Medicare, Medicaid, CHIP, TRICARE, or VA benefits. The savings card applies at the pharmacy counter and is typically processed as a secondary payment after your primary BCBSAZ benefit (Boehringer Ingelheim Jardiance savings program).

The decision framework below summarizes how to sequence your coverage check before your first Jardiance fill:

Step 1: Log into your BCBSAZ member portal or call the pharmacy benefit number on your insurance card to confirm Jardiance's current formulary tier on your specific plan.

Step 2: Ask your prescriber's office to initiate the PA request before calling in the prescription. Filling the prescription without PA approval on a plan that requires PA results in a full out-of-pocket charge at the pharmacy.

Step 3: If PA is approved, ask the pharmacist to apply both your BCBSAZ benefit and the Boehringer Ingelheim savings card simultaneously (if you are commercially insured and not Medicare/Medicaid).

Step 4: If PA is denied, contact your prescriber within 48 hours to initiate an internal appeal before the pharmacy attempts a second fill.

Alternatives If Jardiance Is Not Covered or Is Too Expensive

If Jardiance is denied or the cost-sharing is unmanageable, several alternatives exist within and outside the SGLT2 class.

Preferred SGLT2 Inhibitors on BCBSAZ Formularies

BCBSAZ formularies may place dapagliflozin (Farxiga) or canagliflozin (Invokana) on a lower tier than Jardiance in a given plan year. Dapagliflozin carries FDA approval for type 2 diabetes glycemic control, cardiovascular risk reduction, HFrEF, and CKD. The DAPA-HF trial (N=4,744) showed dapagliflozin 10 mg reduced the composite of worsening heart failure or cardiovascular death by 26% versus placebo (hazard ratio 0.74, 95% CI 0.65 to 0.85, P<0.001) (McMurray JJV et al., NEJM, 2019). If your prescriber agrees that dapagliflozin is clinically appropriate, switching to the preferred formulary agent may eliminate the PA hurdle entirely and reduce your monthly cost significantly.

Step Therapy Considerations

Some BCBSAZ plans require step therapy, meaning a patient must try and fail a preferred agent before coverage of a non-preferred drug like Jardiance is approved. Arizona law (ARS Section 20-3321) limits step therapy requirements and gives physicians the right to request a step therapy exception when clinical circumstances make the preferred agent inappropriate. Your prescriber can document contraindications or prior adverse effects to bypass step therapy.

Patient Assistance Programs

Boehringer Ingelheim operates a Patient Assistance Program (PAP) for uninsured or underinsured patients who meet income eligibility criteria. Income thresholds and application procedures are available through the NeedyMeds database (NeedyMeds, needymeds.org) or directly through Boehringer Ingelheim's patient support line. This program provides Jardiance at no cost for qualifying patients and is separate from the commercial savings card.

How to Confirm Your Specific BCBSAZ Coverage Right Now

Generic guidance about formulary tiers has real limits. BCBSAZ administers dozens of plan designs for different employer groups, individuals, and Medicare Advantage beneficiaries, and formularies are updated annually. The only authoritative answers come from three sources:

Source 1: BCBSAZ Online Member Portal

Log in at azblue.com with your member credentials. Manage to "Prescription Drug Coverage" or "Formulary Search." Enter "empagliflozin" or "Jardiance" and select the correct drug strength (10 mg or 25 mg). The portal displays the current formulary tier, any PA or step therapy requirements, and the quantity limits that apply to your plan.

Source 2: BCBSAZ Member Services Phone Line

Call the pharmacy benefit number on the back of your insurance card. Ask specifically: (1) Is Jardiance covered on my formulary? (2) What tier is it? (3) Does my plan require prior authorization for Jardiance? (4) Does my plan apply step therapy for SGLT2 inhibitors? Write down the representative's name, the date, and the reference number for the call.

Source 3: Your Prescribing Physician's Office

Most physician offices with BCBSAZ patients have a benefits coordinator or prior authorization specialist who can run a real-time eligibility and benefit check before writing the prescription. This is the fastest path because the PA request can be initiated in the same workflow.

The ADA's 2024 Standards of Care note that "access to medications, including affordability and insurance coverage, is a critical component of diabetes care and should be addressed proactively at every clinical encounter" (ADA Standards of Care 2024, Diabetes Care). Asking your prescriber's office to run a coverage check before the prescription is sent to the pharmacy is consistent with that guidance and prevents the frustration of a rejected pharmacy claim.

Special Situations That Affect BCBSAZ Jardiance Coverage

Newly Diagnosed Heart Failure or CKD

If your prescriber is adding Jardiance for a cardiac or renal indication rather than (or in addition to) type 2 diabetes, the PA criteria may differ from the diabetes PA pathway. The cardiology or nephrology specialist managing your care may need to submit the PA rather than your primary care physician, and the supporting documentation should reference the relevant indication-specific trial data (EMPEROR-Reduced for HFrEF, EMPA-KIDNEY for CKD).

The EMPA-KIDNEY trial (N=6,609) demonstrated that empagliflozin 10 mg reduced the risk of kidney disease progression or cardiovascular death by 28% compared to placebo (hazard ratio 0.72, 95% CI 0.64 to 0.82, P<0.001) in patients with CKD at risk of progression (The EMPA-KIDNEY Collaborative Group, NEJM, 2023). Citing this trial in the PA documentation for a CKD-indication request may help expedite approval.

Mid-Year Plan Changes

If your employer changes plan designs mid-year, your formulary may change. Arizona's BCBSAZ commercial plans typically lock formulary changes to the plan's annual benefit period, but employer-sponsored plans that switch carriers mid-year can create coverage gaps. In that scenario, ask BCBSAZ for a transition fill, which allows a short-term supply (typically 30 days) while a new PA is processed.

Low-Income Subsidy (LIS) and Dual-Eligible Members

If you are enrolled in both Medicare and Arizona Medicaid (AHCCCS), your Jardiance coverage is determined by your AHCCCS-contracted plan formulary, not your Medicare Advantage plan. AHCCCS covers empagliflozin for qualifying diagnoses, but the specific preferred agent and PA requirements under each AHCCCS managed care contract should be confirmed directly with your plan.