Does Anthem Cover Jardiance?

Anthem Formulary Placement for Jardiance

Anthem Blue Cross Blue Shield covers Jardiance on the majority of its commercial, Marketplace, and Medicare Advantage formularies. The drug typically lands on Tier 3 (preferred brand) or Tier 4 (non-preferred brand), which means higher cost-sharing than generics but still within the plan's covered benefit.

How Anthem Formulary Tiers Work

Anthem organizes covered medications into tiers that determine how much a member pays at the pharmacy counter. Tier 1 holds low-cost generics. Tier 2 includes preferred generics and select brands. Tiers 3 and 4 are reserved for brand-name drugs, with Tier 3 carrying lower copays than Tier 4. Some Anthem plans add a Tier 5 for specialty medications. Because no generic version of empagliflozin exists in the U.S. Market, Jardiance cannot appear on generic tiers.

Variation Across Anthem Plan Types

The exact tier depends on which Anthem product a member carries. Anthem offers employer-sponsored group plans, individual Marketplace (ACA) plans, Medicaid managed care in select states, and Medicare Advantage plans through its parent company, Elevance Health. Each product line maintains its own formulary. An employer group plan in Virginia may place Jardiance on Tier 3 with a $45 copay, while an Anthem Silver Marketplace plan in California might list it on Tier 4 with a $90 copay after deductible. Members should always verify placement by logging into the Anthem member portal or calling the number on the back of their insurance card.

Checking Your Specific Formulary

Anthem publishes searchable drug lists at anthem.com/pharmacyinformation. Enter "empagliflozin" or "Jardiance," select the plan year, and the tool will display the tier, any quantity limits, and whether prior authorization or step therapy applies. Pharmacists can also run a real-time benefit check at the point of sale that reflects the member's exact plan design.

What You Will Pay Out of Pocket

Cost-sharing for Jardiance through Anthem depends on plan tier, deductible structure, and whether the member qualifies for manufacturer or plan-level savings programs. The retail price of Jardiance without insurance sits near $620 per month for the 10 mg or 25 mg tablet supply 1.

Commercial Plan Copays

On a typical Anthem employer plan with Jardiance on Tier 3, expect a copay between $30 and $60 per 30-day supply. If the drug falls on Tier 4, copays climb to $75 to $100 or higher. Plans with coinsurance instead of flat copays may charge 25% to 50% of the negotiated price, which could mean $100 to $200 monthly before any savings card is applied.

Medicare Advantage Cost-Sharing

Anthem Medicare Advantage plans (marketed in many states as Anthem Blue Cross Medicare Advantage) follow the Part D benefit structure. During the initial coverage phase, empagliflozin copays commonly range from $47 to $100 per month. Once a member enters the coverage gap, the Inflation Reduction Act's $2,000 annual out-of-pocket cap on Part D drugs (effective since 2025) limits total prescription spending, which significantly helps members who take multiple brand-name medications 2.

Manufacturer Savings Programs

Boehringer Ingelheim offers the Jardiance Savings Card for commercially insured patients. Eligible members pay as little as $10 per month, with the card covering up to $300 in copay costs per fill. The card cannot be used with Medicare, Medicaid, or other federal healthcare programs. Patients who do not qualify for the copay card but face high costs should ask about Boehringer Ingelheim's patient assistance program, which provides Jardiance at no cost to qualifying uninsured or underinsured individuals.

Prior Authorization and Step Therapy Requirements

Some Anthem formularies require prior authorization (PA) before they will cover Jardiance. This is more common on Anthem Marketplace and Medicare Advantage plans than on large employer group plans.

What Triggers a Prior Authorization

Anthem's PA criteria for Jardiance typically require documentation that the patient has a diagnosis of type 2 diabetes and has tried or has a contraindication to metformin. For heart failure or chronic kidney disease indications, Anthem may require confirmation of the specific diagnosis code (ICD-10) and evidence that guideline-directed medical therapy is in place. The prescribing clinician submits the PA form electronically or by fax, and Anthem generally responds within 72 hours for standard requests or 24 hours for urgent requests.

Step Therapy Protocols

Step therapy means Anthem requires the member to try one or more lower-cost medications before it will approve coverage for Jardiance. The most common step therapy sequence requires a documented trial of metformin (or a clinical reason metformin is inappropriate, such as an eGFR below 30 mL/min/1.73m² or a history of lactic acidosis). Some Anthem plans also require a trial of a sulfonylurea or a DPP-4 inhibitor before authorizing an SGLT2 inhibitor. The American Diabetes Association's 2024 Standards of Care recommend SGLT2 inhibitors as a preferred second-line agent after metformin for patients with established atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease, which can support a PA appeal if step therapy is initially imposed 3.

How to Appeal a Denial

If Anthem denies Jardiance coverage, the prescriber can file a formulary exception request. The strongest appeals cite the ADA Standards of Care, the patient's specific cardiovascular or renal risk profile, and any documented intolerance to alternative agents. Anthem must respond to a standard exception within 72 hours and to an expedited exception within 24 hours.

Why Prescribers Choose Jardiance: Clinical Evidence

Jardiance earned its first FDA approval in 2014 for type 2 diabetes and has since accumulated cardiovascular, heart failure, and renal outcome data that few oral medications can match.

Cardiovascular Outcomes

The EMPA-REG OUTCOME trial (N=7,020) randomized patients with type 2 diabetes and established cardiovascular disease to empagliflozin 10 mg, empagliflozin 25 mg, or placebo. Over a median 3.1 years of follow-up, empagliflozin reduced cardiovascular death by 38% (HR 0.62, 95% CI 0.49-0.77, P<0.001) and hospitalization for heart failure by 35% compared with placebo 4. This trial made empagliflozin the first diabetes drug to demonstrate a cardiovascular mortality benefit in a dedicated outcomes study.

Heart Failure Data

The EMPEROR-Reduced trial (N=3,730) enrolled patients with heart failure and a left ventricular ejection fraction of 40% or less, regardless of diabetes status. Empagliflozin reduced the composite of cardiovascular death or heart failure hospitalization by 25% (HR 0.75, 95% CI 0.65-0.86, P<0.001) 5. The EMPEROR-Preserved trial (N=5,988) extended this benefit to patients with heart failure and an ejection fraction above 40%, showing a 21% reduction in the same composite endpoint 6. These results led the FDA to approve Jardiance for heart failure across the ejection fraction spectrum in 2022.

Kidney Protection

The EMPA-KIDNEY trial (N=6,609) enrolled patients with chronic kidney disease (with or without diabetes) and demonstrated a 28% reduction in the composite of kidney disease progression or cardiovascular death (HR 0.72, 95% CI 0.64-0.82, P<0.001). The trial was stopped early for efficacy 7. The FDA approved Jardiance for chronic kidney disease in 2023 based on these results, making it one of two SGLT2 inhibitors (alongside dapagliflozin) with a CKD indication.

Guideline Positioning

The ADA and the European Association for the Study of Diabetes (EASD) consensus report positions SGLT2 inhibitors as preferred agents for patients with type 2 diabetes who have or are at high risk for atherosclerotic cardiovascular disease, heart failure, or CKD, independent of A1C level and independent of metformin use 3. The American College of Cardiology and the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines offer similar recommendations for heart failure and CKD populations respectively 8.

Jardiance vs. Farxiga on Anthem Formularies

Because Anthem negotiates rebates separately with each manufacturer, Jardiance and Farxiga (dapagliflozin) may sit on different tiers within the same Anthem plan. In many 2026 Anthem formularies, Farxiga holds a preferred brand position while Jardiance is non-preferred, or vice versa. The clinical profiles overlap substantially, but there are differences worth noting.

Head-to-Head Formulary Comparison

On Anthem plans where Farxiga is Tier 3 and Jardiance is Tier 4, switching to Farxiga can save $20 to $60 per month in copay costs. Both drugs belong to the SGLT2 inhibitor class. Both have FDA approvals for type 2 diabetes, heart failure, and chronic kidney disease. The DAPA-HF and DAPA-CKD trials established dapagliflozin's outcome benefits in heart failure and CKD, paralleling the EMPEROR and EMPA-KIDNEY data for empagliflozin 9. No head-to-head randomized trial has compared empagliflozin and dapagliflozin directly.

When Switching Makes Sense

If both drugs are clinically appropriate and the patient has no specific tolerability reason to stay on Jardiance, choosing the preferred-tier SGLT2 inhibitor is a reasonable cost-saving strategy. Prescribers should confirm with the patient's specific Anthem formulary before writing the switch. Some patients do report different gastrointestinal or genitourinary side effect profiles between the two agents, so a conversation about individual experience matters.

Other SGLT2 Options

Steglatro (ertugliflozin) is a third SGLT2 inhibitor available in the U.S. It has cardiovascular safety data from the VERTIS CV trial but did not demonstrate superiority over placebo for the primary composite cardiovascular endpoint, unlike empagliflozin and dapagliflozin 10. Steglatro sometimes sits on a lower tier but is less commonly prescribed due to its narrower evidence base.

Anthem Medicare Advantage: Special Considerations

Medicare Advantage plans through Anthem follow Part D formulary rules, which differ from commercial plan formularies in several ways.

Part D Formulary Requirements

CMS requires all Part D plans to cover at least two drugs per therapeutic class. SGLT2 inhibitors qualify as a distinct class, so Anthem Medicare Advantage plans must cover at least two of the three available agents. Jardiance is covered on most Anthem Medicare Advantage Part D formularies, though it may require prior authorization or sit on a higher tier than Farxiga.

The $2,000 Out-of-Pocket Cap

Starting in 2025, the Inflation Reduction Act capped annual Part D out-of-pocket spending at $2,000. For Medicare members taking Jardiance along with other brand-name drugs, this cap may be reached within the first few months of the year. After reaching the cap, the member pays nothing for covered Part D drugs for the rest of the calendar year 2. This dramatically changes the cost calculus for Medicare members on expensive brand medications.

Low Income Subsidy (Extra Help)

Medicare members who qualify for the Low Income Subsidy pay $0 to $11.20 per prescription regardless of tier. Anthem Medicare Advantage members who qualify for Extra Help should see minimal copays for Jardiance.

Lowering Your Jardiance Costs on Anthem

Several strategies can reduce out-of-pocket spending on Jardiance beyond the manufacturer copay card.

Ask About Therapeutic Alternatives

If Jardiance is non-preferred on your Anthem plan but Farxiga is preferred, ask your prescriber whether a switch is clinically appropriate. Both drugs reduce cardiovascular events, heart failure hospitalizations, and kidney disease progression in their respective outcome trials.

Use Anthem's Preferred Pharmacy Network

Anthem plans often negotiate lower copays at preferred pharmacies. Mail-order pharmacy options through Express Scripts or Anthem's own pharmacy benefit may offer a 90-day supply at the cost of two monthly copays, saving roughly one month's copay every quarter.

Request a Formulary Exception

If Jardiance is medically necessary and the plan requires step therapy you have already satisfied (or cannot safely attempt), the prescriber can request a formulary exception to move Jardiance to a lower cost-sharing tier. Documentation should include the patient's diagnosis, relevant lab values (A1C, eGFR, BNP), prior medication trials, and supporting guideline citations.

Explore Patient Assistance

Uninsured patients or those facing true financial hardship can apply to Boehringer Ingelheim's patient assistance program for free Jardiance. Eligibility is income-based, typically requiring household income at or below 400% of the federal poverty level.

Side Effects and Monitoring on Jardiance

SGLT2 inhibitors carry a consistent side effect profile across the class. Anthem does not typically mandate specific monitoring as a coverage condition, but standard clinical practice includes baseline and periodic lab work.

Common Side Effects

Genital mycotic infections (yeast infections) are the most frequent adverse event, occurring in approximately 6% of women and 3% of men taking empagliflozin in clinical trials 4. Urinary tract infections occur at rates modestly higher than placebo. Increased urination is expected given the drug's mechanism of promoting glucose excretion through the kidneys.

Serious but Rare Risks

Diabetic ketoacidosis (DKA) can occur with SGLT2 inhibitors even at normal blood glucose levels (euglycemic DKA). The FDA issued a safety communication in 2015 regarding this risk 11. Patients should be counseled to stop Jardiance before major surgery and during acute illness with reduced oral intake. Fournier's gangrene (necrotizing fasciitis of the perineum) is exceedingly rare but has been reported across the SGLT2 class.

Recommended Lab Monitoring

Prescribers should check renal function (serum creatinine and eGFR) before starting Jardiance and periodically thereafter. The 2024 ADA Standards of Care note that SGLT2 inhibitors can be initiated in patients with eGFR as low as 20 mL/min/1.73m² for cardiorenal benefit, though the glucose-lowering effect diminishes below eGFR 45 3. Potassium levels deserve attention in patients with CKD or those taking ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists concurrently.