Does Blue Cross Blue Shield of North Carolina Cover Jardiance?

BCBS NC Formulary Placement for Jardiance

Blue Cross Blue Shield of North Carolina lists Jardiance (empagliflozin) on its commercial formularies as a preferred brand medication, most often placed at Tier 2 or Tier 3. This means the drug is covered but carries a higher cost-share than generic alternatives like metformin.

Formulary placement can shift between plan years. BCBS NC publishes updated drug lists each January for its Blue Value, Blue Select, Blue Advantage, and State Health Plan products. Jardiance has maintained preferred brand status across most of these plans since its FDA approval in 2014 [1]. The distinction between Tier 2 and Tier 3 matters: a Tier 2 copay on a typical BCBS NC PPO plan runs $40 to $75 per fill, while a Tier 3 placement may cost $75 to $150 or more before any manufacturer discount.

For Medicare Advantage enrollees under Blue Medicare HMO or Blue Medicare PPO, Jardiance coverage follows the plan's Part D formulary. These formularies classify it as a non-preferred brand on some contracts, which pushes the copay higher until catastrophic coverage kicks in. Checking the specific Summary of Benefits document for your plan year is the only reliable way to confirm your tier [2].

BCBS NC also offers a State Health Plan (covering roughly 727,000 North Carolina state employees and dependents) that has historically placed SGLT2 inhibitors in a preferred position given their cardiovascular and renal benefits.

Prior Authorization and Step Therapy Requirements

Most BCBS NC plans require prior authorization before they will pay for Jardiance. This is standard. Your prescriber submits clinical documentation showing that the medication is medically necessary for your diagnosis.

BCBS NC's prior authorization criteria for SGLT2 inhibitors typically require three things: a confirmed diagnosis of type 2 diabetes (or heart failure or chronic kidney disease, depending on the indication), an HbA1c level documented within the past 90 days, and evidence that the patient has tried or cannot tolerate metformin [3]. Step therapy is the formal term for that metformin requirement. If your physician documents a contraindication to metformin (such as an eGFR below 30 mL/min/1.73m² or a history of lactic acidosis), the step therapy requirement can be waived.

The American Diabetes Association's 2024 Standards of Care now recommend SGLT2 inhibitors as first-line add-on therapy (or even as initial combination therapy with metformin) for patients with established atherosclerotic cardiovascular disease, heart failure, or diabetic kidney disease [4]. This guideline change has made step therapy overrides easier to obtain when prescribers cite the ADA position directly.

Turnaround time for a standard prior authorization decision is 15 calendar days under North Carolina insurance regulations. Urgent requests (for patients who would face harm from delay) must be decided within 72 hours.

What Jardiance Costs Under BCBS NC Plans

Your actual cost depends on four variables: your plan's formulary tier, whether you have met your annual deductible, your coinsurance percentage, and whether you use the manufacturer's copay assistance program.

Before meeting the deductible, you may pay the full retail price. Jardiance's average wholesale price is approximately $620 per month for the 25 mg tablet [5]. Once the deductible is satisfied, a typical BCBS NC commercial plan applies a copay of $40 to $75 (Tier 2) or $75 to $150 (Tier 3). Some high-deductible health plans paired with an HSA apply coinsurance of 20% to 40% after the deductible, which could mean $124 to $248 per month at list price.

Boehringer Ingelheim's copay savings card can reduce the out-of-pocket cost to as low as $10 per month for commercially insured patients, covering up to $300 per fill. This card does not apply to government insurance (Medicare, Medicaid, Tricare). Medicare Part D enrollees may qualify for the Extra Help/Low-Income Subsidy program through the Social Security Administration, which can reduce copays to $4.50 to $11.20 per generic-equivalent fill or $0 for those below 135% of the federal poverty level [6].

Clinical Evidence Supporting Coverage

Insurers cover Jardiance in part because of its strong clinical trial record, which goes beyond glucose lowering alone.

The EMPA-REG OUTCOME trial (N=7,020) demonstrated that empagliflozin reduced the risk of cardiovascular death by 38% (hazard ratio 0.62 to 95% CI 0.49 to 0.77, P<0.001) compared to placebo in patients with type 2 diabetes and established cardiovascular disease over a median follow-up of 3.1 years [7]. That trial changed how payers and clinicians view SGLT2 inhibitors. Dr. Silvio Inzucchi, then-director of the Yale Diabetes Center, stated: "EMPA-REG OUTCOME was the first trial to show a diabetes drug could actually reduce cardiovascular death, not just lower blood sugar" [8].

The EMPEROR-Preserved trial (N=5,988) later showed empagliflozin reduced the combined risk of cardiovascular death or hospitalization for heart failure by 21% (HR 0.79 to 95% CI 0.69 to 0.90, P<0.001) in patients with heart failure and preserved ejection fraction, regardless of diabetes status [9]. This finding expanded the FDA-approved indication for Jardiance beyond diabetes and into heart failure with an ejection fraction above 40%.

The EMPA-KIDNEY trial (N=6,609) demonstrated a 28% reduction in the progression of kidney disease or cardiovascular death (HR 0.72 to 95% CI 0.64 to 0.82, P<0.001) among patients with chronic kidney disease [10]. The trial was stopped early for efficacy.

Dr. Christoph Wanner, principal investigator of EMPA-REG OUTCOME, noted: "The renal protection we observed was consistent across subgroups, including patients with and without baseline albuminuria, suggesting a broad protective mechanism beyond glycemic control" [11].

These outcomes data give prescribers strong ammunition when filing prior authorization requests or appeals with BCBS NC.

How to Get Jardiance Approved by BCBS NC

Getting coverage starts with your prescriber, not with you calling the insurer directly. Here is the typical workflow.

First, your physician submits a prior authorization request through the BCBS NC provider portal or by fax. The request should include your current HbA1c, a list of diabetes medications you have already tried (especially metformin), any contraindications to step therapy alternatives, and the specific FDA-approved indication being targeted. If you have documented cardiovascular disease, heart failure, or CKD stage 3 or higher, cite the ADA Standards of Care recommendation for SGLT2 inhibitor use [4].

Second, if the initial PA is denied, you have the right to a first-level appeal. Your physician should submit a letter of medical necessity that references the relevant clinical trials (EMPA-REG OUTCOME, EMPEROR-Preserved, or EMPA-KIDNEY depending on the indication). BCBS NC must respond to a standard appeal within 30 calendar days. An expedited appeal for urgent situations requires a response within 72 hours.

Third, if the first appeal fails, North Carolina law allows an external review by an independent review organization (IRO). The North Carolina Department of Insurance oversees this process. The IRO's decision is binding on BCBS NC [12].

A practical tip: if you are prescribed Jardiance for heart failure or CKD rather than for diabetes, make sure the PA request specifies the correct ICD-10 code (I50.x for heart failure or N18.x for CKD) rather than defaulting to E11.x (type 2 diabetes). Matching the diagnosis code to the indication can prevent unnecessary denials related to diabetes-specific step therapy criteria.

Jardiance vs. Other SGLT2 Inhibitors on BCBS NC Formularies

BCBS NC covers multiple SGLT2 inhibitors, and the relative formulary placement between them can affect which one your physician prescribes.

Farxiga (dapagliflozin), manufactured by AstraZeneca, sits at a similar tier to Jardiance on most BCBS NC formularies. The DAPA-HF trial (N=4,744) showed dapagliflozin reduced cardiovascular death or worsening heart failure by 26% (HR 0.74 to 95% CI 0.65 to 0.85, P<0.001) in patients with heart failure and reduced ejection fraction [13]. Invokana (canagliflozin) is also covered but may be placed at a higher tier or carry additional PA requirements due to its boxed warning history (the amputation warning was later removed by the FDA in 2020).

If your insurer's preferred SGLT2 inhibitor is dapagliflozin rather than empagliflozin, switching to the preferred agent will typically lower your copay. Both medications belong to the same drug class and have broadly similar cardiovascular and renal outcomes data. The ADA does not recommend one SGLT2 inhibitor over another for most patients [4].

For plans that require trying a less expensive SGLT2 option first, your physician can document clinical reasons to prefer Jardiance specifically, such as the EMPA-REG OUTCOME data in a patient with atherosclerotic cardiovascular disease, or the EMPEROR-Preserved data in a patient with HFpEF.

Special Situations: Medicaid, Marketplace, and Employer Plans

BCBS NC administers several different insurance products, and coverage rules differ across them.

North Carolina Medicaid (NC Medicaid Managed Care, launched in 2024) covers SGLT2 inhibitors including Jardiance as part of its pharmacy benefit. Prior authorization is required, and the state's Preferred Drug List determines whether empagliflozin or dapagliflozin is the first-line option. Copays under Medicaid are nominal, typically $1 to $4 per prescription [14].

ACA Marketplace plans (Blue Local, Blue Select, Blue Home) sold through HealthCare.gov follow the BCBS NC standard formulary. These plans must cover at least one drug in each pharmacologic class under the ACA's essential health benefits requirement, which guarantees access to at least one SGLT2 inhibitor. If Jardiance is not the covered agent, a formulary exception request can be filed.

Large employer self-funded plans administered by BCBS NC may have custom formularies. Some large employers negotiate direct rebates with pharmaceutical manufacturers that change which drugs are preferred. If your employer plan does not cover Jardiance, the HR benefits team can confirm whether a formulary exception process exists.

Reducing Out-of-Pocket Costs Beyond Insurance

Even with BCBS NC coverage, Jardiance can be expensive. Several strategies can lower your costs.

The Boehringer Ingelheim copay card is the most widely used option for commercial patients. It applies automatically at participating pharmacies and can bring the copay down to $10 per month. Enrollment is available through the Jardiance website or through your prescriber's office. The card has an annual maximum benefit (typically $3,600 per calendar year), which resets each January.

Patient assistance programs (PAPs) are available for uninsured or underinsured patients. Boehringer Ingelheim's patient assistance program provides Jardiance at no cost to qualifying patients whose household income is at or below 400% of the federal poverty level.

Pharmacy benefit optimization is another angle. Using a BCBS NC preferred pharmacy (such as a 90-day mail-order option through Prime Therapeutics, BCBS NC's pharmacy benefit manager) can reduce per-unit costs. A 90-day supply typically costs 2.0 to 2.5 times the 30-day copay rather than 3 times, saving roughly one month's copay per quarter [15].

For Medicare Part D enrollees, the Inflation Reduction Act capped annual out-of-pocket pharmacy spending at $2,000 starting in 2025, which limits total exposure for expensive brand medications like Jardiance regardless of tier placement [16].

When Coverage Is Denied: Your Rights Under NC Law

A denial is not the final answer. North Carolina insurance law provides a structured appeals pathway that patients and prescribers can use.

After an initial denial, your explanation of benefits (EOB) will include the specific reason for the denial and instructions for filing an appeal. Common denial reasons for Jardiance include failure to complete step therapy (the metformin trial), incomplete clinical documentation, or off-label use not supported by the plan's medical policy.

The first internal appeal goes to BCBS NC's clinical review team. A physician reviewer (not the same person who issued the initial denial) evaluates the case. If this appeal is denied, you can request an external review through the North Carolina Department of Insurance. The external review is conducted by an independent organization with no financial ties to BCBS NC, and its decision is binding [12].

During the appeals process, you can request a continuation of coverage if you were previously receiving Jardiance and the denial is due to a formulary change or re-authorization requirement. This prevents a gap in treatment while the appeal is pending.

Time matters. You generally have 180 days from the date of the denial to file an internal appeal under North Carolina law.