Does Blue Cross Blue Shield of Minnesota Cover Jardiance?

What Jardiance Is and Why Coverage Matters

Jardiance is the brand name for empagliflozin, a sodium-glucose cotransporter-2 (SGLT2) inhibitor that lowers blood glucose by blocking glucose reabsorption in the kidney. The FDA first approved it in August 2014 for glycemic control in adults with type 2 diabetes [1]. Since then, two additional indications have widened its use considerably.

Three FDA-Approved Indications

In August 2021 the FDA approved empagliflozin to reduce cardiovascular death and hospitalization in adults with heart failure with reduced ejection fraction (HFrEF), based on the EMPEROR-Reduced trial [2]. In February 2023 the agency extended that approval to heart failure with preserved ejection fraction (HFpEF) following EMPEROR-Preserved [3]. A drug with three distinct indications may face different coverage rules depending on which diagnosis code appears on the claim.

Why the List Price Creates Access Barriers

Without insurance, Jardiance carries a wholesale acquisition cost of roughly $646 per 30-tablet supply. That price has made insurer prior authorization (PA) decisions financially significant for patients. The American Diabetes Association's 2024 Standards of Care explicitly state that "SGLT2 inhibitors with proven cardiovascular or kidney benefit are recommended for people with type 2 diabetes and established cardiovascular disease or high cardiovascular risk" [4]. When a guideline-recommended drug sits on a high formulary tier, patients and prescribers must manage a PA process before coverage activates.

How BCBS Minnesota Formularies Are Structured

Blue Cross Blue Shield of Minnesota operates several distinct plan types, and each uses its own formulary document.

Commercial vs. Medicare Advantage vs. Medicaid

BCBS MN's commercial group plans (employer-sponsored) use a tiered formulary typically running from Tier 1 (preferred generics) through Tier 4 or Tier 5 (specialty/non-preferred brands). Medicare Advantage plans (branded as Blue Cross Medicare Advantage) follow CMS formulary rules [5] and publish a separate Annual Notice of Change each fall. Minnesota's public-program administrator (formerly known as UCare, now reorganized) is separate from commercial BCBS MN, so Medicaid enrollees should verify through Minnesota DHS directly.

Where Jardiance Typically Falls

Across most BCBS MN commercial formularies reviewed as of 2024, empagliflozin lands on Tier 3 (preferred brand) or Tier 4 (non-preferred brand). Tier 3 copays commonly run $50 to $100 per 30-day supply after the deductible. Tier 4 copays commonly run $100 to $200 per fill, and if you are in a high-deductible health plan (HDHP), you may owe the full negotiated cost until you meet your deductible, which can exceed $1,500 on a single medication. Always pull your specific Summary of Benefits and Coverage (SBC) or the online formulary lookup at bcbsmn.com to confirm.

Formulary Exceptions and Non-Formulary Requests

If Jardiance is listed as non-formulary on your plan, your prescriber may file a formulary exception. The exception request typically requires documentation that formulary alternatives are medically contraindicated or have been tried and failed. CMS regulations require Medicare Part D plans to respond to standard exception requests within 72 hours and expedited requests within 24 hours [5].

Prior Authorization Requirements for Jardiance

Most BCBS MN plans require PA before they will pay for Jardiance. Understanding the typical criteria lets your prescriber submit a complete, approvable request the first time.

Common PA Criteria

Plans vary, but most BCBS MN PA policies for Jardiance include a requirement that the patient carries a confirmed diagnosis of type 2 diabetes (ICD-10 E11.x), heart failure (I50.x), or chronic kidney disease (N18.x). For the diabetes indication, many policies additionally require an A1C above a defined threshold, commonly 7.0 to 8.0%, documented within the prior 90 to 180 days. The prescriber's specialty and the clinical setting may affect how quickly the PA is reviewed [6].

Step Therapy: The Metformin and Generic SGLT2 Hurdle

Step therapy means the insurer requires you to try and fail a less expensive drug before approving the requested agent. For Jardiance in the type 2 diabetes indication, most BCBS MN commercial plans require documented metformin use or a contraindication to metformin. Metformin remains the first-line agent recommended by both the ADA [4] and the American Association of Clinical Endocrinologists (AACE) 2023 guidelines [7].

Some plans add a second step requiring a trial of a lower-cost SGLT2 inhibitor. Dapagliflozin (Farxiga) and canagliflozin (Invokana) are the two most commonly specified alternatives. If your plan covers dapagliflozin at a lower tier, the PA policy may require a 30-day or 90-day trial before Jardiance is approved.

Appealing a Denied PA

If BCBS MN denies the initial PA, the prescriber may file a first-level internal appeal. Minnesota state law requires insurers to complete standard internal appeals within 30 days and expedited appeals within 72 hours for urgent situations [8]. If the internal appeal fails, you have the right to an external independent review through the Minnesota Department of Commerce. The external reviewer's decision is binding on the insurer.

Clinical Evidence Supporting Jardiance Coverage Arguments

When your prescriber drafts a PA or appeal letter, citing the specific trial data is more persuasive than general language. The trials below are the ones most often referenced in coverage determinations.

EMPA-REG OUTCOME: Cardiovascular Mortality

EMPA-REG OUTCOME (N=7,020) randomized adults with type 2 diabetes and established cardiovascular disease to empagliflozin 10 or 25 mg versus placebo on top of standard care. After a median follow-up of 3.1 years, the empagliflozin group showed a 14% relative risk reduction in the primary 3-point MACE endpoint (HR 0.86, 95% CI 0.74 to 0.99, P<0.001 for non-inferiority; P=0.04 for superiority) [9]. Cardiovascular death alone fell by 38%. This trial is the most frequently cited when appealing a denial for a patient with established atherosclerotic cardiovascular disease (ASCVD).

EMPEROR-Reduced: Heart Failure with Reduced Ejection Fraction

In EMPEROR-Reduced (N=3,730), empagliflozin 10 mg reduced the composite of cardiovascular death or hospitalization for heart failure by 25% versus placebo (HR 0.75, 95% CI 0.65 to 0.86, P<0.001) [2]. The benefit appeared regardless of whether patients had diabetes. This data underpins the 2021 HFrEF FDA approval and is directly relevant to PA requests submitted under the heart failure diagnosis code.

EMPEROR-Preserved: Heart Failure with Preserved Ejection Fraction

EMPEROR-Preserved (N=5,988) showed a 21% reduction in the composite primary endpoint of CV death or HF hospitalization (HR 0.79, 95% CI 0.69 to 0.90, P<0.001) [3]. This trial was the first to demonstrate a statistically significant benefit of any agent in HFpEF, a condition affecting roughly half of all heart failure patients in the United States [10].

EMPA-KIDNEY: Chronic Kidney Disease

EMPA-KIDNEY (N=6,609) enrolled adults with CKD at risk of progression, about 46% of whom did not have diabetes. Empagliflozin 10 mg reduced the risk of kidney disease progression or cardiovascular death by 28% versus placebo (HR 0.72, 95% CI 0.64 to 0.82, P<0.001) [11]. The FDA granted an expanded CKD indication based in part on this evidence. A PA request for a patient with diabetic nephropathy should reference both the CKD diagnosis code and this trial.

Alternatives BCBS MN May Prefer Over Jardiance

Knowing what your plan considers "preferred" lets you have a more productive conversation with your prescriber about whether switching makes clinical sense or whether an appeal is warranted.

Generic SGLT2 Inhibitors

As of 2024, generic empagliflozin is not yet available in the United States. Canagliflozin (Invokana) lost patent exclusivity, and some generic versions entered the market in 2023, making it a lower-cost option on some plans [12]. Dapagliflozin (Farxiga) remains brand-only. If your plan tiers generic canagliflozin below Jardiance, step therapy to canagliflozin first is clinically reasonable for the diabetes indication, though CREDENCE (N=4,401) showed canagliflozin's kidney protection, while EMPA-KIDNEY and EMPEROR showed empagliflozin's data independently [13].

GLP-1 Receptor Agonists as Formulary Alternatives

Some BCBS MN PA criteria list a GLP-1 receptor agonist (such as semaglutide or dulaglutide) as an acceptable alternative to an SGLT2 inhibitor for patients with ASCVD but without heart failure or CKD. The ADA 2024 Standards note that "for patients with type 2 diabetes and established CVD or high CV risk, a GLP-1 RA or SGLT2 inhibitor with proven benefit is recommended" [4]. The two drug classes have different cardiovascular effect profiles, so your prescriber can argue that the SGLT2 mechanism is specifically needed if the patient has HF or CKD.

Metformin and DPP-4 Inhibitors

Metformin remains fully generic and sits at Tier 1 on virtually every BCBS MN formulary. DPP-4 inhibitors such as sitagliptin (Januvia) are typically Tier 2 or Tier 3. Neither class carries the heart failure hospitalization reduction or kidney protection data that SGLT2 inhibitors have [4], which gives prescribers a strong clinical argument when the patient has those comorbidities.

Cost-Reduction Strategies If You Face High Out-of-Pocket Costs

Even with coverage, Tier 3 or Tier 4 cost-sharing can strain budgets. Several programs can reduce what you actually pay at the pharmacy.

The Jardiance Savings Card

Boehringer Ingelheim and Eli Lilly offer a copay savings card for commercially insured patients. Eligible patients may pay as little as $10 per 30-day fill, with a maximum benefit of up to $150 per fill and an annual cap that varies by program year. Medicare beneficiaries are not eligible for manufacturer copay cards under federal anti-kickback rules, but they may qualify for Extra Help (Low Income Subsidy) through Social Security [5].

Patient Assistance Programs

The Lilly Insulin Value Program and Boehringer Ingelheim Cares Foundation offer free or reduced-cost medication to uninsured or underinsured patients who meet income criteria, generally at or below 400% of the federal poverty level. Applications are submitted through the manufacturer's patient support line or directly online.

90-Day Supply and Mail-Order Pharmacies

BCBS MN plans commonly offer a lower per-day cost for 90-day mail-order fills versus 30-day retail fills. If your copay is $100 for a 30-day supply at retail, the 90-day mail-order cost may be $200 to $225, saving roughly $75 over three months.

GoodRx and Discount Cards

GoodRx and similar discount programs are not insurance and cannot be combined with insurance at most pharmacies. For patients who have not yet met their deductible and are paying full cost, a GoodRx coupon may reduce the out-of-pocket cost to $400 to $500 per month at certain pharmacies, which is below the $646 list price but still substantially above the copay card amount available to commercially insured patients.

How to Work With Your Prescriber to Get Approval

A denial is not a final answer. Structured documentation submitted upfront increases first-pass PA approval rates.

Information Your Prescriber Should Include in the PA

The PA package should include your current A1C value with the date drawn, a list of prior diabetes medications with start and stop dates, the specific ICD-10 diagnosis codes (E11.x for T2D, I50.x for HF, N18.x for CKD), any documented contraindications to formulary alternatives, and a brief clinical narrative citing the relevant trial (EMPA-REG OUTCOME, EMPEROR-Reduced, EMPA-KIDNEY) as applicable to your case. Payers review hundreds of PAs per day. A complete, well-organized submission reduces the chance of a request for additional information that adds days to the process [6].

What "Medically Necessary" Means in This Context

BCBS MN, like all commercial insurers, covers services and drugs that are medically necessary, defined in most member contracts as "consistent with generally accepted standards of medical practice." The ADA 2024 Standards [4] and the 2022 AHA/ACC/HFSA Heart Failure Guidelines [14] both recommend empagliflozin for specific populations. Quoting the guideline recommendation verbatim in an appeal letter provides a clear anchor for the "generally accepted standards" standard.

Requesting a Peer-to-Peer Review

After a PA denial, your prescriber can request a peer-to-peer (P2P) review, a phone call between your doctor and the plan's medical director. Studies suggest that peer-to-peer reviews overturn PA denials roughly 30 to 75% of the time depending on specialty and condition [6]. The P2P call should happen before filing a formal appeal because it is faster and leaves the formal appeal pathway open if the P2P fails.

Medicare Advantage Considerations for BCBS MN Members

BCBS MN's Medicare Advantage (MA) products follow a distinct set of rules from commercial plans.

CMS Formulary Requirements

CMS requires all MA Prescription Drug plans to cover at least two drugs in each therapeutic category. SGLT2 inhibitors form their own class under USP guidelines, so plans must cover at least two agents [5]. That does not guarantee Jardiance specifically is covered, but it does mean at least two SGLT2 options must appear on the formulary.

Coverage Gap and Extra Help

Medicare Part D has an annual out-of-pocket threshold. In 2025, the Inflation Reduction Act capped annual Part D out-of-pocket costs at $2,000 for all beneficiaries, a change that meaningfully reduces exposure for patients taking high-tier brand drugs like Jardiance [5]. Patients with income below 150% of the federal poverty level may qualify for Low Income Subsidy (Extra Help), which can reduce Tier 4 brand copays to $0 to $10 per month on MA-PD plans.

Star Ratings and Preferred Pharmacy Networks

MA plans with higher CMS Star Ratings sometimes offer enhanced drug benefits. BCBS MN's Blue Cross Medicare Advantage has historically maintained 4-star or higher ratings in Minnesota. A preferred pharmacy network may offer a lower cost-sharing tier for Jardiance compared to a standard network pharmacy, so confirming which pharmacies are "preferred" under your specific plan can reduce out-of-pocket cost without changing the formulary tier.