Does Blue Cross Blue Shield of Illinois Cover Jardiance?

What Is Jardiance and Why Does Coverage Matter?

Jardiance (empagliflozin) is an SGLT2 inhibitor approved by the FDA for three distinct indications. The FDA first cleared it for type 2 diabetes management in August 2014, then expanded the label in 2021 to reduce cardiovascular death in adults with heart failure with reduced ejection fraction, and again in 2023 to slow chronic kidney disease progression in adults at risk of kidney failure. [1]

Because Jardiance carries three separate approved uses, coverage decisions at BCBSIL can differ depending on which diagnosis code appears on the prescription. A cardiologist writing for heart failure may trigger different formulary rules than an endocrinologist writing for type 2 diabetes, even though the tablet is identical.

Why SGLT2 Inhibitors Are Now Standard of Care

The EMPA-REG OUTCOME trial (N=7,020) demonstrated that empagliflozin reduced the risk of cardiovascular death by 38% relative to placebo in patients with type 2 diabetes and established cardiovascular disease (hazard ratio 0.62; 95% CI 0.49-0.77; P<0.001). [2] The EMPEROR-Reduced trial (N=3,730) then showed that empagliflozin reduced the composite of cardiovascular death or heart failure hospitalization by 25% versus placebo in patients with heart failure with reduced ejection fraction. [3]

These outcomes data repositioned SGLT2 inhibitors from "add-on glucose-lowering agents" to first-line cardioprotective therapy. The 2023 American Diabetes Association Standards of Care explicitly state that "in patients with type 2 diabetes and established or high risk of atherosclerotic cardiovascular disease, heart failure, or CKD, an SGLT2 inhibitor with demonstrated benefit is recommended." [4] That guideline language gives prescribers clinical ammunition when writing prior authorization letters.

The EMPEROR-Preserved Evidence Extending Coverage Rationale

The EMPEROR-Preserved trial (N=5,988) found that empagliflozin reduced the primary composite endpoint of cardiovascular death or heart failure hospitalization by 21% in patients with heart failure with preserved ejection fraction (HR 0.79; 95% CI 0.69-0.90; P<0.001). [5] Insurers, including BCBSIL, have begun integrating this evidence into coverage criteria, though not all plans have updated their formulary language to reflect it as of early 2025.

How BCBSIL Formularies Work

BCBSIL does not operate a single formulary. The company administers dozens of plan designs across fully insured commercial, self-funded employer, Medicaid managed care (through Blue Cross Community Health Plans), and Medicare Advantage. Each plan may use a different drug list, tier structure, and cost-sharing schedule. [6]

Commercial Plan Formularies

Most BCBSIL commercial plans organize drugs into four or five tiers:

• Tier 1: Preferred generics (lowest copay, often $0-$15)
• Tier 2: Non-preferred generics and preferred brands
• Tier 3: Preferred brands (moderate copay, often $40-$75)
• Tier 4: Non-preferred brands (higher copay, often $90-$150+)
• Tier 5 (some plans): Specialty drugs

Jardiance typically appears at Tier 3 on BCBSIL preferred formularies when prior authorization criteria are met, and at Tier 4 when the plan defaults to requiring step therapy through a less expensive alternative first.

Because no FDA-approved generic empagliflozin exists as of January 2025, members cannot simply switch to a generic to reduce cost. Dapagliflozin (Farxiga) and canagliflozin (Invokana) are the two closest alternatives in the same class, and some BCBSIL step therapy protocols require a trial of one of these before approving Jardiance. [7]

Medicare Advantage and Part D Plans

BCBSIL Medicare Advantage plans follow CMS Part D formulary rules. Under 2025 Medicare Part D redesign provisions from the Inflation Reduction Act, out-of-pocket drug costs are capped at $2,000 per year for beneficiaries. Jardiance appears on most BCBSIL Medicare Advantage formularies at Tier 3 or Tier 4, with prior authorization required. CMS guidance allows Medicare plans to require PA for brand-name drugs when a therapeutic alternative exists in the same class. [8]

Prior Authorization Requirements for Jardiance at BCBSIL

Prior authorization is the single largest obstacle members face when filling Jardiance through BCBSIL. The PA process exists because Jardiance is expensive, retailing at roughly $600-$650 per 30-day supply without insurance as of early 2025, and because generic alternatives in adjacent classes (metformin, sulfonylureas) cost under $15 per month.

Typical PA Criteria BCBSIL Uses

PA criteria vary by plan year and plan type, but BCBSIL commercial plans commonly require one or more of the following before approving Jardiance:

1. A confirmed diagnosis of type 2 diabetes, heart failure, or CKD with supporting lab values or clinical documentation.
2. Documentation that the patient has tried at least one preferred formulary alternative (often metformin for diabetes indications, or a generic loop diuretic for heart failure).
3. An HbA1c above a specified threshold (often 7.5% or higher) if the indication is glycemic control.
4. Prescriber attestation that the patient has a specific cardiovascular or renal comorbidity that makes Jardiance medically necessary over a cheaper alternative.

The 2023 ADA Standards of Care state that SGLT2 inhibitors "should be used in patients with type 2 diabetes and CKD to reduce the risk of CKD progression and cardiovascular events." [4] Citing this language verbatim in a PA letter improves approval odds.

How Long PA Takes in Illinois

Illinois law (215 ILCS 5/155.22b) requires that health insurers process standard prior authorization requests within 2 business days of receiving all necessary clinical information, and within 1 business day for urgent requests. If BCBSIL does not respond within those windows, the request is considered approved by operation of law.

Step Therapy Protocols

Some BCBSIL plans require step therapy, meaning the member must try and fail a specified drug before Jardiance will be covered. Illinois enacted the Step Therapy Reform Act (Public Act 100-0956), which took effect January 1, 2020. Under this law, insurers must allow exceptions to step therapy when:

• The required step-therapy drug is contraindicated or likely to cause adverse effects.
• The member already tried and failed the required drug within the prior 5 years.
• The required drug is not in the member's best interest based on clinical judgment.
• The member is stable on their current therapy.

Prescribers invoking these exceptions must submit clinical notes, lab results, and a written statement explaining why the step-therapy drug is inappropriate. Approvals under the Illinois Step Therapy Reform Act must be processed within the same PA timeframes described above.

How to Check Your Specific BCBSIL Plan's Jardiance Coverage

Coverage details are plan-specific. The most reliable verification method is a direct formulary check, not a phone call alone.

Step-by-Step Verification

1. Log into your BCBSIL member portal at bcbsil.com and manage to "Find a Drug" or "Drug Cost Estimator."
2. Search for "empagliflozin" or "Jardiance." The tool will display your plan's tier placement, any PA requirements, and your estimated copay or coinsurance.
3. Call the pharmacy benefits number on the back of your insurance card and ask specifically: (a) What tier is Jardiance on my plan? (b) Is prior authorization required? (c) Does my plan require step therapy?
4. Ask your pharmacy to run a test claim before you pick up the prescription. The pharmacy's claims system will return a real-time eligibility response showing your exact cost share.

If your plan is self-funded (common with large Illinois employers), BCBSIL administers claims but your employer sets the formulary. Self-funded plan formularies may differ substantially from the standard BCBSIL commercial formulary.

Cost-Reduction Options When BCBSIL Coverage Is Partial or Denied

Even with partial coverage or a PA denial, members have several concrete paths to reducing Jardiance costs. The options below are layered in order of how quickly they can be accessed.

Boehringer Ingelheim Savings Card

Boehringer Ingelheim offers a commercial savings card that reduces Jardiance cost to as low as $10 per month for eligible commercially insured patients. The card is available at jardiance.com/savings. Eligibility requirements include having commercial insurance (Medicare and Medicaid beneficiaries do not qualify) and meeting income thresholds in some program versions. The savings card is compatible with most BCBSIL commercial plans when Jardiance is on formulary.

Patient Assistance Program

Boehringer Ingelheim's "Lilly Cares" and "Boehringer Ingelheim Cares" programs provide Jardiance at no cost to uninsured or underinsured patients who meet income criteria. Applications are processed through needymeds.org and the manufacturer's own portal. Approval timelines average 2-4 weeks.

Appeal a Denied PA

BCBSIL must provide a written denial with the specific reason for rejection and instructions for filing an internal appeal. Under Illinois law and the Affordable Care Act, members have the right to:

• An internal appeal (processed within 30 days for non-urgent requests, 72 hours for urgent cases).
• An external independent review by an entity not affiliated with BCBSIL if the internal appeal fails.

The FDA's approval of Jardiance for cardiovascular death reduction in the EMPA-REG OUTCOME trial [2] and CKD progression in the EMPA-KIDNEY trial (N=6,609, primary endpoint HR 0.72; 95% CI 0.64-0.82; P<0.001) [9] provides strong clinical grounds for appeals on those indications.

Therapeutic Substitution Under Protest

If appeals fail and cost remains prohibitive, dapagliflozin (Farxiga) may be covered at a lower tier on your BCBSIL plan. The DAPA-HF trial (N=4,744) demonstrated that dapagliflozin reduced the composite of worsening heart failure or cardiovascular death by 26% versus placebo (HR 0.74; 95% CI 0.65-0.85; P<0.001), an outcome profile comparable to Jardiance. [10] Ask your prescriber whether dapagliflozin is a clinically acceptable substitute given your specific diagnosis before switching.

What Prescribers Can Do to Maximize Approval Rates

Physicians and nurse practitioners writing Jardiance prescriptions for BCBSIL patients can improve PA success rates by following a structured documentation approach.

Documentation Best Practices

Include all of the following in the PA submission:

• Current HbA1c (if diabetes indication), most recent eGFR (if CKD indication), or most recent echocardiogram LVEF (if heart failure indication).
• Cardiovascular comorbidity list: documented ASCVD, prior MI, prior stroke, or peripheral artery disease.
• Prior drug trial history, including drug name, dose, duration, and reason for discontinuation.
• Specific reference to the ADA 2023 Standards of Care recommendation for SGLT2 inhibitors in high-risk patients. [4]
• Reference to the EMPA-REG OUTCOME or EMPEROR-Reduced or EMPA-KIDNEY trial results as applicable to the patient's diagnosis.

Peer-to-Peer Review

If an initial PA is denied, request a peer-to-peer review call with the BCBSIL medical director reviewing the case. Cardiologists and endocrinologists with board certification can cite the trial-level mortality data directly. The EMPA-REG OUTCOME result (38% relative risk reduction in cardiovascular death) [2] is difficult for a plan medical director to dismiss when the patient has documented ASCVD and type 2 diabetes.

Illinois Insurance Regulations That Protect Members

Illinois has several consumer-protection rules that are directly relevant to Jardiance coverage disputes.

The Illinois Insurance Code requires that formulary exceptions be granted when a covered drug is not therapeutically equivalent to a plan's preferred alternative, or when a covered drug causes an adverse effect. Jardiance's three distinct FDA-approved indications (diabetes, heart failure, CKD) create multiple pathways to argue medical necessity when a different SGLT2 inhibitor is listed as preferred.

The Illinois Department of Insurance maintains a consumer complaints division that members can contact when BCBSIL exceeds PA processing timelines or denies appeals improperly. Filing a formal complaint often accelerates internal resolution. Contact information is available at insurance.illinois.gov.

The No Surprises Act, effective January 2022, does not apply directly to formulary disputes, but it established federal infrastructure for independent dispute resolution that state regulators now reference when setting external review standards. [11]

Specific Populations and Coverage Nuances

Patients with Type 1 Diabetes

Jardiance does not carry an FDA label for type 1 diabetes. BCBSIL will almost certainly deny a PA request for Jardiance when the diagnosis code is E10.x (type 1 diabetes). The FDA declined to approve empagliflozin for type 1 due to diabetic ketoacidosis risk signals observed in the inTandem and EASE trial programs. [12] Prescribers should not submit Jardiance PA requests for type 1 diabetes through BCBSIL.

Pediatric Patients

The FDA approved empagliflozin for patients aged 10 years and older with type 2 diabetes in December 2023, based on the DINAMO trial data. [13] BCBSIL pediatric formulary coverage for Jardiance in patients aged 10-17 is evolving. Pediatric endocrinologists should confirm formulary status separately, as pediatric plan formularies sometimes lag adult formulary updates by 6-12 months.

Pregnant Patients

Jardiance carries FDA pregnancy category guidance advising against use in the second and third trimesters due to potential adverse fetal renal effects. BCBSIL will typically not approve Jardiance for pregnant members, and prescribers should not request it for this population. [1]

Real-World Cost Scenarios for BCBSIL Members

To make these abstractions concrete, consider three scenarios that illustrate how coverage plays out differently depending on plan design.

Scenario A: A 58-year-old with type 2 diabetes and documented coronary artery disease on a BCBSIL PPO plan. Her plan places Jardiance at Tier 3 with PA required. Her prescriber submits a PA citing EMPA-REG OUTCOME and the 2023 ADA guidelines. PA is approved in 2 business days. Her copay is $55 per 30-day supply. She applies the Boehringer Ingelheim savings card and pays $10.

Scenario B: A 67-year-old on a BCBSIL Medicare Advantage plan with heart failure and an LVEF of 35%. His plan places Jardiance at Tier 4 with PA required and step therapy through furosemide (a diuretic, not an SGLT2 inhibitor). His cardiologist invokes the Illinois Step Therapy Reform Act exception, noting that furosemide treats symptoms but does not reduce mortality. PA is approved after peer-to-peer review. His cost share is $95 per month after Part D applies, capped at $2,000 annually under the 2025 IRA rules.

Scenario C: A 44-year-old with CKD stage 3b (eGFR 38 mL/min/1.73 m2) on a self-funded employer plan administered by BCBSIL. The employer's formulary does not list Jardiance at all. His nephrologist files a formulary exception request citing EMPA-KIDNEY trial data. [9] The request is denied at internal appeal. The member pursues external independent review and wins, as the EMPA-KIDNEY evidence is now guideline-supported by the 2022 KDIGO CKD guideline update. [14]