Does Amerigroup Cover Jardiance?

How Amerigroup Formulary Coverage Works for Jardiance

Amerigroup operates as a managed care organization under Elevance Health (formerly Anthem, Inc.), serving Medicaid, Medicare Advantage, and Children's Health Insurance Program (CHIP) populations across more than 20 states. Each state negotiates its own formulary, which means Jardiance coverage is not identical from Georgia to Texas to Washington.

Formulary Tier Placement

In most Amerigroup state formularies reviewed for 2025 and 2026, Jardiance appears on a preferred brand tier (Tier 2) or non-preferred brand tier (Tier 3). A Tier 2 placement typically means a copay between $25 and $75 for a 30-day supply under Medicare Advantage plans. For Medicaid enrollees, copays are often capped at $1 to $4 per prescription under federal Medicaid rules, though this varies by state 1.

Prior Authorization and Step Therapy

Amerigroup commonly requires prior authorization (PA) for Jardiance. The PA criteria in most state plans follow a predictable pattern: the prescriber must document that the patient has tried and failed metformin, or has a contraindication to metformin such as an estimated glomerular filtration rate (eGFR) below 30 mL/min/1.73 m², chronic metabolic acidosis, or a history of lactic acidosis. Some state plans also require documentation of a recent hemoglobin A1c value.

The American Diabetes Association (ADA) 2024 Standards of Care recommend SGLT2 inhibitors as add-on therapy for patients with type 2 diabetes who have established atherosclerotic cardiovascular disease (ASCVD), heart failure, or chronic kidney disease (CKD), regardless of A1c level 2. Citing this guideline in a PA request can strengthen the case for approval.

Why Amerigroup Requires Prior Authorization for SGLT2 Inhibitors

Prior authorization exists because SGLT2 inhibitors like Jardiance carry a higher per-unit cost than older generic diabetes medications. Metformin costs roughly $4 to $20 per month at most pharmacies, while Jardiance runs $580 to $620 at retail. For a Medicaid managed care plan covering millions of lives, even a small percentage shift in prescribing patterns translates to tens of millions of dollars.

The Clinical Justification

PA is not only a cost measure. SGLT2 inhibitors have a distinct side-effect profile that warrants clinical review. The EMPA-REG OUTCOME trial (N=7,020) demonstrated that empagliflozin reduced cardiovascular death by 38% and hospitalization for heart failure by 35% in patients with type 2 diabetes and established cardiovascular disease 3. These benefits are clinically significant, but the drug also carries risks: genital mycotic infections occurred in 6.4% of women on empagliflozin versus 1.5% on placebo, and rare cases of diabetic ketoacidosis (DKA), including euglycemic DKA, have been reported 4.

What Happens if PA Is Denied

If Amerigroup denies the PA, the prescriber can file a formal appeal. Federal Medicaid regulations require that managed care plans provide a written denial with the specific clinical reason and offer an appeal process that must be resolved within 30 days for standard requests or 72 hours for expedited requests. During the appeal, documenting the ADA guideline recommendation and the patient's specific cardiovascular or renal risk factors often results in reversal.

Jardiance Coverage by Amerigroup Plan Type

Coverage details differ based on whether the member is enrolled in Medicaid, Medicare Advantage, or a marketplace plan administered by Amerigroup.

Amerigroup Medicaid Plans

Most Amerigroup Medicaid plans cover Jardiance with PA. Copays for Medicaid beneficiaries are capped by federal law: no more than $4 for preferred brand drugs and $8 for non-preferred brands for members with income above 150% of the federal poverty level (FPL). Members below 150% FPL typically pay $1 to $3 1.

State-specific Medicaid formularies can change quarterly. The most reliable way to check current coverage is to call the Amerigroup pharmacy department using the number on the back of the member's ID card or use the Amerigroup online formulary search tool for the specific state.

Amerigroup Medicare Advantage Plans

Amerigroup's Medicare Advantage plans (offered through Wellpoint, the Medicare-facing brand of Elevance Health) typically place Jardiance on Tier 3 (preferred brand) or Tier 4 (non-preferred brand). Copays during the initial coverage phase range from $42 to $100 per 30-day supply.

The Inflation Reduction Act (IRA) of 2022 capped total out-of-pocket prescription drug costs for Medicare Part D beneficiaries at $2,000 per year starting in 2025 5. For patients on multiple brand-name medications, this cap provides meaningful protection. A patient taking Jardiance at $75 per month copay plus insulin at $35 per month (insulin is separately capped at $35/month under the IRA) would hit the $2,000 ceiling within roughly 22 months of combined non-insulin brand copays.

Checking Your Specific Plan

The fastest method to verify coverage:

1. Log in to the Amerigroup member portal for your state.
2. Manage to "Pharmacy" or "Find a Drug."
3. Search for "empagliflozin" or "Jardiance."
4. Review the tier, PA requirement, quantity limits, and any step therapy rules listed.

If the online tool is unavailable, call Amerigroup Member Services. Have the prescriber's NPI number and the patient's diagnosis codes (E11.65 for type 2 diabetes with hyperglycemia, I50.x for heart failure) ready.

How to Lower Your Jardiance Cost with Amerigroup

Even with insurance coverage, out-of-pocket costs for Jardiance can strain household budgets. Several options exist.

Boehringer Ingelheim Savings Card

The manufacturer offers a copay savings card that reduces the cost to as low as $10 per month for commercially insured patients. This card is not valid for Medicaid, Medicare, or other federal or state healthcare program beneficiaries 6.

State Pharmaceutical Assistance Programs (SPAPs)

Some states operate SPAPs that supplement Medicaid or Medicare drug coverage. New York's EPIC program, New Jersey's PAAD, and Pennsylvania's PACE are examples. Eligibility is typically income-based.

Patient Assistance Programs

Boehringer Ingelheim's Lilly Cares/BI Cares patient assistance program provides free Jardiance to qualifying patients with income at or below 400% FPL who lack prescription drug coverage. The application requires prescriber involvement and proof of income.

Switching to a Covered Alternative

If Jardiance remains unaffordable or is not covered, other SGLT2 inhibitors may have better formulary placement on the patient's specific Amerigroup plan. Farxiga (dapagliflozin) and Invokana (canagliflozin) belong to the same drug class. Farxiga, in particular, gained FDA approval for CKD independent of diabetes status, and some Amerigroup state formularies place it on a lower (less expensive) tier than Jardiance.

Clinical Evidence Supporting Jardiance Coverage Requests

Strong clinical trial data can make the difference between a PA approval and a denial. Prescribers should cite specific evidence when submitting PA requests to Amerigroup.

Cardiovascular Outcomes

The EMPA-REG OUTCOME trial enrolled 7,020 patients with type 2 diabetes and established cardiovascular disease across 42 countries. Empagliflozin 10 mg or 25 mg daily reduced the primary composite endpoint of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke by 14% (hazard ratio 0.86, 95% CI 0.74 to 0.99, P=0.04) compared with placebo over a median follow-up of 3.1 years 3.

Heart Failure Outcomes

The EMPEROR-Reduced trial (N=3,730) showed that empagliflozin 10 mg daily reduced the combined risk of cardiovascular death or hospitalization for heart failure by 25% (HR 0.75, 95% CI 0.65 to 0.86, P<0.001) in patients with heart failure and a reduced ejection fraction, regardless of diabetes status 7. The EMPEROR-Preserved trial (N=5,988) later extended this benefit to patients with heart failure and a preserved ejection fraction, showing a 21% reduction in the same composite endpoint (HR 0.79, 95% CI 0.69 to 0.90, P<0.001) 8.

Kidney Outcomes

The EMPA-KIDNEY trial (N=6,609) demonstrated that empagliflozin 10 mg daily reduced the risk of kidney disease progression or cardiovascular death by 28% (HR 0.72, 95% CI 0.64 to 0.82, P<0.001) in patients with CKD, with or without diabetes 9. This trial is particularly relevant for PA requests in patients whose primary indication is CKD rather than glycemic control.

Dr. Christoph Wanner, principal investigator of EMPA-REG OUTCOME, stated: "Empagliflozin is the first glucose-lowering agent to demonstrate a reduction in cardiovascular death in patients with type 2 diabetes at high cardiovascular risk" 3.

The 2024 KDIGO Clinical Practice Guideline for Diabetes Management in CKD recommends SGLT2 inhibitors as first-line therapy alongside metformin for patients with type 2 diabetes and CKD with an eGFR of 20 mL/min/1.73 m² or higher 10.

Amerigroup Jardiance Coverage by State: Key Differences

Because Amerigroup contracts individually with each state's Medicaid program, formulary placement, PA criteria, and copay amounts differ. Below is a general overview of patterns observed across major Amerigroup states.

States with Preferred Brand Coverage

In Texas, Georgia, and Tennessee, Amerigroup Medicaid formularies have historically placed Jardiance on Tier 2 (preferred brand) with standard PA requirements. These states represent some of Amerigroup's largest Medicaid populations.

States with Non-Preferred or Restricted Coverage

In some states, Amerigroup places Jardiance on a non-preferred brand tier, meaning higher copays and stricter PA criteria. In these states, the plan may prefer a different SGLT2 inhibitor (often Farxiga) or require failure of two first-line agents before approving Jardiance.

How Formularies Change

State Medicaid formularies typically update quarterly. Amerigroup's Pharmacy and Therapeutics (P&T) committee reviews new clinical evidence, FDA label changes, pricing shifts, and supplemental rebate agreements with manufacturers. A drug that is non-preferred today may become preferred in the next quarter if the manufacturer offers a better rebate.

The Medicaid Drug Rebate Program (MDRP) requires manufacturers to pay rebates to state Medicaid programs for covered outpatient drugs. The minimum rebate is 23.1% of the average manufacturer price (AMP) for brand-name drugs 11. Supplemental rebates negotiated by Amerigroup or the state can exceed this floor, and these supplemental agreements heavily influence tier placement.

What to Do If Amerigroup Denies Jardiance Coverage

A denial is not the end. There are structured steps to pursue.

Step 1: Read the Denial Letter

Federal regulations require the denial letter to state the specific clinical reason. Common reasons include: patient has not tried metformin, insufficient documentation of cardiovascular or renal comorbidities, or the drug is non-formulary in the patient's state.

Step 2: File a Peer-to-Peer Review

The prescribing physician can request a peer-to-peer review with the Amerigroup medical director. During this call, the physician presents the clinical rationale directly. Having trial data (EMPA-REG OUTCOME, EMPEROR-Reduced, EMPA-KIDNEY) and the ADA Standards of Care recommendation ready is helpful.

Step 3: Submit a Formal Appeal

If peer-to-peer review does not resolve the issue, a formal written appeal can be submitted. Include the patient's complete medication history, lab results (A1c, eGFR, urine albumin-to-creatinine ratio), diagnosis codes, and supporting guideline citations.

As Dr. Robert Gabbay, Chief Scientific and Medical Officer of the American Diabetes Association, noted in the 2024 Standards of Care: "For patients with type 2 diabetes and established ASCVD, heart failure, or CKD, an SGLT2 inhibitor or GLP-1 receptor agonist with demonstrated cardiovascular benefit is recommended independent of A1c" 2.

Step 4: Request a State Fair Hearing

Medicaid beneficiaries have the right to a state fair hearing if internal appeals are exhausted. This is an administrative hearing before an independent reviewer, and decisions are binding on the plan.

Jardiance Dosing and What Amerigroup Typically Authorizes

Jardiance is available in 10 mg and 25 mg tablets. For type 2 diabetes, the FDA-approved starting dose is 10 mg once daily, with an option to increase to 25 mg. For heart failure (with or without diabetes), the approved dose is 10 mg once daily 12.

Most Amerigroup PA approvals authorize a quantity limit of 30 tablets per 30 days (one tablet daily). Requests for 25 mg may require documentation that the patient was on 10 mg for a minimum duration (often 4 to 12 weeks) without adequate glycemic response.

Refill authorizations are typically valid for 6 to 12 months, after which the prescriber may need to resubmit PA documentation. Some Amerigroup state plans have moved to 12-month authorization periods to reduce administrative burden.