Does Blue Cross Blue Shield of Arizona Cover Jardiance?

What Is Jardiance and Why Does Coverage Matter?

Jardiance (empagliflozin) is an oral SGLT2 inhibitor manufactured by Boehringer Ingelheim and Eli Lilly. The FDA approved it first in 2014 for type 2 diabetes management, then expanded that label to cardiovascular risk reduction in 2016, heart failure with reduced ejection fraction in 2021, and chronic kidney disease in 2023 [1][2]. Because it now carries four distinct indications, it shows up on more formularies than earlier-generation diabetes drugs, but it still carries a brand-name price tag that makes insurance coverage genuinely consequential.

Without coverage, a 30-day supply of Jardiance runs $600 to $700 at most Arizona pharmacies. For a patient taking it indefinitely for chronic kidney disease, that adds up to roughly $7,200 to $8,400 per year out of pocket. That number alone explains why patients, caregivers, and prescribers spend considerable time sorting out BCBSAZ formulary rules before writing or filling the prescription.

BCBSAZ is Arizona's largest commercial health insurer, covering approximately 1.5 million members across individual, employer-sponsored, and Medicare Advantage product lines [3]. Each product line has its own formulary, so the phrase "BCBSAZ covers Jardiance" is accurate only as a general statement. Your specific plan document is what governs.

Coverage decisions for branded drugs like Jardiance hinge on three separate questions: Is the drug on the formulary at all? What tier is it on, and what does that tier cost you? Does your plan impose prior authorization (PA) or step therapy before approving it? The sections below answer each question systematically.

How BCBSAZ Formularies Are Structured

Most BCBSAZ commercial plans use a five-tier formulary structure. Tier 1 covers low-cost generics, Tier 2 covers preferred generics or select OTC drugs, Tier 3 covers preferred brand-name drugs, Tier 4 covers non-preferred brands, and Tier 5 is reserved for specialty medications. Jardiance most commonly lands on Tier 3 in BCBSAZ commercial plans, which typically carries a copay of $50 to $100 per 30-day fill, depending on your specific benefit design.

Medicare Advantage formularies follow CMS tiering rules and may place Jardiance on a different tier. CMS Part D formularies often list Jardiance as a Tier 3 or Tier 4 drug, which can mean a co-insurance percentage rather than a flat copay [4]. For members in a BCBSAZ Medicare Advantage plan, the annual coverage gap ("donut hole") was effectively closed for most drugs by the Inflation Reduction Act's $2,000 annual out-of-pocket cap, which takes full effect in 2025 [5].

Marketplace (ACA) plans sold under the BCBSAZ brand follow state and federal formulary requirements but retain significant flexibility in tiering. Bronze and Silver plans tend to carry higher cost-sharing for Tier 3 drugs than Gold or Platinum plans.

The fastest way to confirm your plan's current Jardiance tier is to use the BCBSAZ online drug lookup tool at the member portal (az.com) or call the pharmacy benefits number on the back of your insurance card. Formularies can change on January 1 of each plan year, so confirming at the start of each year matters.

Prior Authorization: What BCBSAZ Typically Requires

Prior authorization is the most common barrier patients face with Jardiance on BCBSAZ plans. PA is a process by which your prescriber must submit clinical documentation proving that Jardiance is medically necessary for you specifically before the plan will pay for it.

BCBSAZ PA criteria for Jardiance generally include one or more of the following: a confirmed diagnosis of type 2 diabetes, heart failure with reduced ejection fraction (HFrEF), or chronic kidney disease (CKD); evidence that metformin or another first-line agent was tried and either failed to achieve glycemic goals or was contraindicated; documentation of the patient's most recent A1C, eGFR, or LVEF measurement depending on the indication; and confirmation that the prescriber is a licensed provider with prescriptive authority (MD, DO, NP, or PA) [6].

Step therapy, sometimes called "fail first," is a related requirement. Some BCBSAZ plans require documented trial of at least one generic SGLT2 inhibitor or older diabetes medication before approving a branded drug. Currently, no generic empagliflozin exists in the United States. However, dapagliflozin (Farxiga) lost patent exclusivity and generic dapagliflozin became available in 2024. A plan applying generic-first step therapy might ask for a trial of generic dapagliflozin before approving brand-name Jardiance, unless your prescriber documents a clinical reason why empagliflozin specifically is preferred.

Arizona enacted step-therapy reform legislation (A.R.S. section 20-3321 et seq.) that requires insurers to grant step-therapy overrides within 72 hours for non-urgent cases and within 24 hours for urgent cases if the prescriber provides adequate clinical documentation [7]. Your prescriber can invoke this law if a step-therapy requirement is imposing clinically inappropriate delays.

The table below outlines the typical PA submission workflow for Jardiance under BCBSAZ plans. This framework was developed by the HealthRX clinical team based on aggregated prior authorization support cases and is intended as a practical checklist, not a guarantee of approval.

PA Submission Checklist for Jardiance on BCBSAZ Plans

1. Prescriber obtains PA form from BCBSAZ or submits via CoverMyMeds electronic portal.
2. Prescriber documents primary indication (T2D, HFrEF, CKD, or CV risk reduction).
3. Relevant lab values attached: A1C within 6 months (T2D), eGFR within 6 months (CKD), or echocardiogram/LVEF within 12 months (HFrEF).
4. Documentation of prior therapy: list of agents tried, doses, durations, and outcomes.
5. Attestation of any contraindications to first-line alternatives.
6. Submit. BCBSAZ standard PA turnaround is 3 business days for standard review; expedited review must be completed within 24 hours under Arizona law [7].

The Clinical Evidence That Supports PA Approvals

Insurance plans are more likely to approve Jardiance when the prescriber cites the specific clinical trial evidence that drove FDA label expansions. Knowing this evidence helps your prescriber write a stronger PA letter.

For cardiovascular risk reduction in type 2 diabetes, the EMPA-REG OUTCOME trial (N=7,020) showed that empagliflozin 10 mg or 25 mg daily reduced the composite of cardiovascular death, nonfatal MI, or nonfatal stroke by 14% relative to placebo (10.5% vs. 12.1%, HR 0.86 to 95% CI 0.74-0.99, P<0.001 for noninferiority; P=0.04 for superiority) [8]. CV death specifically was reduced by 38% (3.7% vs. 5.9%, HR 0.62 to 95% CI 0.49-0.77). These numbers appear in the FDA-approved labeling.

For heart failure with reduced ejection fraction, the EMPEROR-Reduced trial (N=3,730) showed empagliflozin 10 mg daily reduced the composite of CV death or hospitalization for heart failure by 25% relative to placebo (19.4% vs. 24.7%, HR 0.75 to 95% CI 0.65-0.86, P<0.001) [9]. The American Heart Association's 2022 Heart Failure Guidelines list SGLT2 inhibitors as a Class I recommendation for patients with HFrEF to reduce hospitalization and mortality [10].

For chronic kidney disease, the EMPA-KIDNEY trial (N=6,609) showed empagliflozin 10 mg daily reduced the composite of kidney disease progression or cardiovascular death by 28% relative to placebo (13.1% vs. 16.9%, HR 0.72 to 95% CI 0.64-0.82, P<0.001) [11].

As the 2023 ADA Standards of Care state: "In patients with type 2 diabetes and established cardiovascular disease or high cardiovascular risk, a GLP-1 receptor agonist or SGLT2 inhibitor with demonstrated cardiovascular benefit is recommended" [12]. A PA letter citing these specific trial numbers and this guideline language gives your prescriber's request the clinical grounding that medical directors look for.

What Happens If BCBSAZ Denies Coverage?

A denial is not a final answer. BCBSAZ, like all Arizona-regulated insurers, must provide a written explanation for any denial and must offer an internal appeal process. After exhausting internal appeals, members have the right to an external independent review under Arizona Department of Insurance regulations [13].

The appeal process typically proceeds in three stages. First, your prescriber submits an internal appeal (sometimes called a reconsideration) with additional clinical documentation within 60 days of the denial notice. Second, if the internal appeal is denied, you or your prescriber can request a second-level internal review. Third, if that is also denied, an independent external review organization chosen by the Arizona Department of Insurance conducts a binding review, typically within 45 days.

Roughly 40 to 60% of initial denials are overturned on appeal when supported by strong physician documentation citing peer-reviewed evidence. Success rates are highest when the prescriber explicitly states why alternatives (such as other SGLT2 inhibitors or different drug classes) are medically inferior for that specific patient.

Your prescriber's office manager or a patient advocate at Boehringer Ingelheim (1-800-545-6962) can assist with preparing appeal documentation. Free patient advocacy organizations such as the Patient Advocate Foundation also provide case management services for medication denials.

Copay Assistance and Manufacturer Savings Programs

Even with insurance coverage, Tier 3 cost-sharing can be meaningful. Boehringer Ingelheim and Eli Lilly offer a Jardiance Savings Card that reduces out-of-pocket costs to as low as $10 per 30-day fill for eligible commercially insured patients, with a maximum benefit of $150 per fill and no annual cap stated in the current program terms [14]. Medicare and Medicaid beneficiaries are not eligible for manufacturer copay cards under federal anti-kickback rules, though Medicare patients may qualify for the Extra Help (Low Income Subsidy) program.

To use the savings card, you must have commercial insurance that covers Jardiance (even if only partially), be a U.S. resident, and not be enrolled in any federal or state government-funded health program. Enrollment is free at the official Jardiance website or through your pharmacist.

If your BCBSAZ plan places Jardiance on a non-covered or excluded tier, the savings card cannot be applied, because the drug must first be a covered benefit. In that scenario, a formulary exception request is the appropriate next step.

Formulary Exception Requests: A Step Beyond PA

A formulary exception asks the plan to cover a drug that is either not on the formulary at all or is at a higher cost-sharing tier than is clinically appropriate for a given patient. BCBSAZ must acknowledge a formulary exception request within 24 hours for urgent cases and 72 hours for standard cases under ACA regulations [6].

The prescriber's letter supporting a formulary exception for Jardiance should address three points. First, it should explain why drugs currently on the preferred tier are not therapeutically equivalent for this patient. For example, a patient with a history of urinary tract infections on canagliflozin may have a clinical reason to switch to empagliflozin. Second, it should cite the trial evidence showing outcome benefits specific to empagliflozin (EMPA-REG OUTCOME, EMPEROR-Reduced, EMPA-KIDNEY). Third, it should attach current lab values demonstrating disease severity.

Medicare Advantage and Jardiance: Special Considerations

BCBSAZ offers several Medicare Advantage products in Arizona, including HMO and PPO options. These plans must follow CMS Part D formulary requirements, which include coverage of all drugs in certain protected classes. Diabetes medications are not in a CMS-protected class, so Medicare Advantage plans retain the right to apply PA, step therapy, and formulary tiering to Jardiance.

For 2025, the Inflation Reduction Act's $2,000 annual out-of-pocket cap on Part D drugs means that even if Jardiance falls on a higher tier with a co-insurance structure, total Part D cost-sharing for Medicare beneficiaries cannot exceed $2,000 for the plan year [5]. The Medicare Extra Help program provides additional subsidies for beneficiaries with incomes below 150% of the federal poverty level, and enrollment is available year-round through the Social Security Administration.

Members in a BCBSAZ Medicare Advantage plan who face Jardiance coverage denials have the right to a Coverage Determination, followed by a Redetermination (internal appeal), then an Independent Review Entity review, and finally escalation to an Administrative Law Judge, all with federally mandated timelines under 42 CFR Part 422 [4].

Checking Your Specific BCBSAZ Plan in Three Steps

Formulary details are plan-specific and change annually. Here is a practical three-step verification method.

Step 1. Log in to the BCBSAZ member portal at az.com and manage to "Find a Drug" under your Pharmacy Benefits section. Enter "empagliflozin" or "Jardiance" and select your plan year. The tool will display the current tier, copay or co-insurance amount, and any PA or step-therapy flags.

Step 2. Call the pharmacy benefits number on the back of your insurance card and ask the representative: "Is Jardiance on my formulary, what tier is it, and does it require prior authorization?" Request a reference number for the call.

Step 3. Ask your prescriber's office to run a real-time eligibility and PA check through their electronic health record or through CoverMyMeds, which integrates directly with BCBSAZ's PA processing system. This step often reveals exactly which clinical criteria need to be met before approval.

Generics, Biosimilars, and the Future of Empagliflozin Pricing

No FDA-approved generic empagliflozin is currently on the U.S. market. Jardiance's core patent expires in 2025, but patent litigation and regulatory timelines mean generic availability may extend into 2026 or later. Once generics arrive, formularies will almost certainly shift empagliflozin to Tier 1 or Tier 2, eliminating most PA and step-therapy requirements. Until then, brand-name Jardiance will remain subject to current coverage rules.

A fixed-dose combination product, Glyxambi (empagliflozin/linagliptin), is also available and carries its own distinct formulary status on BCBSAZ plans. Synjardy (empagliflozin/metformin) similarly has separate formulary placement. If your prescriber is open to a combination product, checking whether those alternatives carry lower tier placement may reduce out-of-pocket cost in the near term.