Does Anthem Cover Jardiance? A Step-by-Step Coverage Guide

What Is Jardiance and Why Does Coverage Matter?

Jardiance is an SGLT-2 inhibitor approved by the FDA for four distinct indications, and each indication affects how Anthem evaluates a prior authorization request. The drug's list price of roughly $665 per 30-day supply makes insurance coverage the difference between affordability and a bill that most patients cannot sustain long-term.

The FDA first approved empagliflozin in August 2014 for glycemic control in adults with type 2 diabetes. Subsequent approvals followed: reducing cardiovascular death risk in adults with T2D and established cardiovascular disease (based on the EMPA-REG OUTCOME trial), treating heart failure with reduced ejection fraction (HFrEF), and reducing chronic kidney disease (CKD) progression. The FDA's full prescribing information lists all four approved uses [1].

Each indication carries a different clinical documentation burden. A patient requesting Jardiance only for glycemic control faces a different prior authorization checklist than one seeking it for HFrEF or CKD. Knowing your specific indication before calling Anthem can cut hours off the approval process.

The American Diabetes Association 2024 Standards of Care recommend SGLT-2 inhibitors as preferred add-on therapy in patients with T2D who have established atherosclerotic cardiovascular disease, heart failure, or CKD, regardless of HbA1c [2]. Anthem's coverage criteria frequently mirror this language, which means a patient with any of those comorbidities may have a stronger coverage argument than one seeking Jardiance purely for glucose lowering.

Does Anthem Actually List Jardiance on Its Formulary?

Anthem places Jardiance on the covered drug list for the majority of its commercial, Medicare Advantage, and Medicaid plans, but the tier assignment differs by product line. Checking your specific formulary is the only way to get a definitive answer.

Anthem operates under the Blue Cross Blue Shield license in 14 states. Each state files its own formulary with regulators, and the SGLT-2 inhibitor tier can differ from state to state. In 2024 and into 2025, most Anthem commercial formularies place Jardiance at Tier 2 (preferred brand) or Tier 3 (non-preferred brand). A Tier 2 placement typically means a copay of $40 to $80 per fill after deductible; Tier 3 can push that to $100 to $200 or more.

For Medicare Advantage and Part D plans, Anthem follows CMS formulary guidelines. CMS requires that Part D plans cover at least two drugs in each therapeutic class [3]. SGLT-2 inhibitors qualify as their own class for drugs with a cardiovascular or renal indication, so Anthem Medicare plans generally list Jardiance, often at Tier 3 or Tier 4 with prior authorization.

How to look up your specific Anthem formulary:

1. Log in to anthem.com with your member credentials.
2. Select "Find a Drug" or "Formulary Search."
3. Enter "empagliflozin" or "Jardiance."
4. Filter by your specific plan name (found on your insurance card).
5. Note the tier, any quantity limits, and any prior authorization or step therapy flags.

Anthem also maintains a pharmacy benefits line (the number is on the back of your member ID card) where a representative can confirm real-time formulary status.

What Does Prior Authorization for Jardiance Require?

Prior authorization (PA) is required on most Anthem plans, and the specific criteria depend on the indication your prescriber submits. Anthem's PA criteria for SGLT-2 inhibitors generally follow the clinical evidence published in large outcomes trials and ADA/ACC guideline language.

For type 2 diabetes glycemic control, Anthem typically requires:

• A confirmed diagnosis of T2D with documentation of HbA1c (usually above 7.0 to 7.5%, though exact thresholds vary by plan).
• Evidence that metformin was tried and either failed, was not tolerated, or is contraindicated. This is the step therapy component.
• A prescribing clinician licensed to manage diabetes (primary care physicians and endocrinologists both qualify).

For cardiovascular risk reduction, the EMPA-REG OUTCOME trial (N=7,020) found that empagliflozin reduced the composite endpoint of cardiovascular death, nonfatal MI, or nonfatal stroke by 14% vs. placebo (HR 0.86 to 95% CI 0.74 to 0.99, P<0.001 for non-inferiority; P=0.04 for superiority), and cut cardiovascular mortality by 38% [4]. Anthem PA criteria for this indication generally require documentation of established ASCVD (prior MI, stroke, or symptomatic PAD).

For HFrEF, the EMPEROR-Reduced trial (N=3,730) showed empagliflozin reduced the primary composite of CV death or hospitalization for heart failure by 25% vs. placebo (HR 0.75 to 95% CI 0.65 to 0.86, P<0.001) [5]. Anthem criteria for this indication typically ask for an echocardiogram or imaging report confirming LVEF of 40% or below, plus concurrent guideline-directed medical therapy.

For CKD, the EMPA-KIDNEY trial (N=6,609) found empagliflozin reduced the risk of kidney disease progression or cardiovascular death by 28% vs. placebo (HR 0.72 to 95% CI 0.64 to 0.82, P<0.001) [6]. Anthem PA criteria for CKD typically require eGFR documentation and UACR results consistent with the trial inclusion criteria (eGFR 20 to 45 mL/min/1.73m², or eGFR 45 to 90 with UACR above 200 mg/g).

The American College of Cardiology's 2022 Expert Consensus Decision Pathway states: "SGLT2 inhibitors are recommended for patients with T2D and established CVD, HF, or CKD to reduce the risk of adverse cardiovascular and kidney outcomes" [7]. Quoting this language in the PA letter often accelerates Anthem's review.

Step Therapy: Do You Have to Try Another Drug First?

Step therapy applies on most Anthem commercial plans, meaning you must document a trial of at least one alternative agent before Jardiance is approved. For the glycemic indication, metformin is almost always the required first step. The ADA 2024 Standards of Care note that metformin remains the preferred initial pharmacologic agent for T2D unless contraindicated [2].

For patients who cannot take metformin due to eGFR below 30 mL/min/1.73m², lactic acidosis history, or intolerance, Anthem can grant a step-therapy exception. Your prescriber should document the contraindication explicitly in the PA submission.

For the cardiovascular or CKD indications, step therapy may be waived entirely, because no other SGLT-2 inhibitor or first-line drug has a direct FDA-approved cardiovascular death-reduction label at the same level of evidence as empagliflozin. Your prescriber's appeal letter should cite EMPA-REG OUTCOME and EMPEROR-Reduced specifically.

Anthem must respond to standard PA requests within 72 hours for non-urgent cases and within 24 hours (or sometimes 1 hour) for urgent cases, per CMS timelines and most state insurance regulations. If you are denied, a peer-to-peer review between your physician and Anthem's medical director resolves approximately 30 to 40% of initial PA denials in the prescriber's favor, based on general insurer peer-to-peer outcomes data.

How Much Will Jardiance Cost With Anthem Coverage?

Out-of-pocket cost depends on four variables: your tier assignment, your plan's deductible, the phase of your Medicare Part D benefit (if applicable), and whether you use the manufacturer's savings card.

Commercial plans (non-Medicare):

• Tier 2 (preferred brand): $40 to $80 per 30-day fill after deductible.
• Tier 3 (non-preferred): $100 to $200 per fill after deductible.
• During deductible phase: You pay the full negotiated rate, which is typically $300 to $500 per 30-day fill at in-network pharmacies.

Medicare Advantage / Part D:

The Inflation Reduction Act (IRA) of 2022 capped Medicare Part D out-of-pocket drug costs at $2,000 per year beginning January 1, 2025 [8]. Once you reach that cap, Jardiance is $0 for the rest of the calendar year. Before the cap, patients in the coverage gap previously faced 25% coinsurance; the IRA eliminated the coverage gap entirely for 2025.

Eli Lilly and Boehringer Ingelheim savings card:

The Jardiance Savings Card is available to commercially insured patients (not eligible for those with government insurance such as Medicare or Medicaid). Eligible patients can pay as little as $10 per 30-day fill, with a monthly maximum benefit of up to $150 and an annual cap of $1,800 [9]. The card is activated at JardiancePro.com or through the prescribing office.

GoodRx and alternatives:

GoodRx prices for empagliflozin 10 mg (30 tablets) ranged from $550 to $620 at major chains in mid-2025, which is below the list price but still higher than a Tier 2 copay. GoodRx cannot be combined with insurance; you choose one or the other at the pharmacy.

What Happens If Anthem Denies Coverage?

A denial is not final. Federal law (ACA Section 2719 and the No Surprises Act framework) and most state regulations require Anthem to provide a written denial with a specific clinical reason, and to offer both an internal appeal and an external independent review [10].

Step 1: Internal appeal. Your prescriber submits a letter citing the clinical trial data, guideline language, and your specific lab values. The EMPA-REG OUTCOME and EMPA-KIDNEY data are particularly persuasive for CV or renal indications. Anthem must respond within 30 days for standard appeals (60 days total under some state rules) or 72 hours for urgent appeals.

Step 2: Peer-to-peer review. Your physician requests a call with Anthem's reviewing medical director. This is separate from the formal appeal and can happen in parallel. Many denials overturn at this stage.

Step 3: External independent review. If the internal appeal fails, you have the right to an independent review organization (IRO) decision under state law or ERISA. The IRO decision is binding on Anthem in most states.

Step 4: State insurance commissioner complaint. Filing a complaint with your state's insurance commissioner creates a regulatory record and sometimes prompts Anthem to revisit the denial.

The HealthRX clinical team has reviewed Anthem PA criteria across eight states and found that PA approval rates for Jardiance increase substantially when the submitting prescriber includes: (a) a copy of the relevant outcomes trial abstract, (b) the patient's current HbA1c or eGFR lab result dated within 90 days, and (c) explicit ADA or ACC guideline language linking the patient's comorbidities to an SGLT-2 inhibitor recommendation. Submissions lacking any one of these three elements are denied at a higher rate on first review.

Anthem Medicare Advantage and Jardiance: Special Considerations

Medicare Advantage (MA) plans sold by Anthem must follow CMS Part D formulary rules, but they have more flexibility than standalone Part D plans in how they structure tiers and cost-sharing. CMS publishes the Medicare Prescription Drug Coverage and Your Rights fact sheet outlining patient protections [3].

For 2025, the $2,000 out-of-pocket cap means that even if Jardiance is at Tier 4 with $150 coinsurance per fill, you will hit the cap after roughly 13 fills and pay nothing for the remainder of the year. Anthem MA members can also use the Medicare Prescription Payment Plan to spread out-of-pocket costs across monthly installments throughout the calendar year [8].

Anthem's MA plans also cover the cardiac rehab and diabetes education services that complement Jardiance therapy. Structured diabetes self-management education (DSME) programs have been shown to reduce HbA1c by 0.57% at 3 to 6 months vs. usual care in a Cochrane review of 21 trials (N=2,833) [11]. Pairing medication access with DSME maximizes clinical outcomes.

Anthem Medicaid and Jardiance

Anthem administers Medicaid managed care in several states including California (Medi-Cal), Virginia, Georgia, and others. Medicaid formularies are set partly by state pharmacy and therapeutics committees and partly by Anthem's contracted formulary decisions.

SGLT-2 inhibitor coverage on Medicaid varies significantly. Some state Medicaid programs have added SGLT-2 inhibitors as preferred agents for patients with T2D and CKD, citing cost-effectiveness data. A 2021 cost-effectiveness analysis in Diabetes Care found that empagliflozin was cost-effective at a threshold of $150,000 per QALY gained for patients with T2D and CKD, primarily due to reductions in dialysis and hospitalization costs [12].

If you are on Anthem Medicaid and Jardiance is not on your state formulary, request a formulary exception in writing. The CKD and heart failure data make a strong medical necessity argument. Patient assistance programs from Boehringer Ingelheim and Eli Lilly can provide Jardiance free of charge to qualifying low-income uninsured or underinsured patients through the Lilly Cares Foundation [13].

How Jardiance Compares to Other SGLT-2 Inhibitors on Anthem Formularies

Anthem formularies also carry canagliflozin (Invokana) and dapagliflozin (Farxiga). Formulary positioning of these three agents differs by plan and state. In some Anthem plans, dapagliflozin is the preferred SGLT-2 inhibitor at a lower tier, while Jardiance is at a higher tier.

The DECLARE-TIMI 58 trial (N=17,160) studied dapagliflozin and found a 17% reduction in the composite of CV death or worsening heart failure (HR 0.83 to 95% CI 0.73 to 0.95, P=0.005) [14]. The CANVAS trial (N=10,142) studied canagliflozin and found a 14% reduction in the primary MACE composite (HR 0.86 to 95% CI 0.75 to 0.97, P=0.02 for superiority), though with an increased amputation signal [15].

No head-to-head trial has directly compared empagliflozin, dapagliflozin, and canagliflozin on cardiovascular outcomes. If Anthem places dapagliflozin at a lower tier on your plan, your prescriber may want to consider whether the clinical evidence supports switching, particularly for HFrEF, where both EMPEROR-Reduced (empagliflozin) and DAPA-HF (dapagliflozin, N=4,744, HR 0.74 for primary endpoint, P<0.001) [16] demonstrated strong benefits.

If your prescriber believes Jardiance specifically is the medically necessary choice (for example, due to the CKD trial data from EMPA-KIDNEY), the PA letter should explain why the lower-tier alternative is inadequate for your clinical situation.

Practical Steps to Get Anthem to Cover Jardiance

Getting coverage approved quickly is largely a documentation exercise. The following process reflects what works based on how Anthem's PA criteria are written.

Before your prescriber submits the PA:

• Pull your most recent HbA1c, eGFR, UACR, and echocardiogram (if applicable) within the past 90 days.
• Confirm your diagnosis codes. ICD-10 E11.65 (T2D with hyperglycemia) differs from I50.20 (HFrEF), and the wrong code can mismatch the PA criteria.
• Ask your prescriber's office to use Anthem's CoverMyMeds or ePA portal, which reduces processing time vs. fax.

In the PA letter itself:

• State the specific FDA-approved indication being requested.
• List any trials of metformin or other agents, including dates, doses, and reason for discontinuation.
• Quote ADA 2024 guideline language (Section 9, "Cardiovascular Disease and Risk Management") or the ACC 2022 Expert Consensus directly [2, 7].
• Include the patient's cardiovascular risk category or CKD stage explicitly.

If denied on first submission:

• Request a peer-to-peer review within 5 business days of the denial notice.
• Have the prescriber cite EMPA-REG OUTCOME (38% CV mortality reduction) and EMPA-KIDNEY (28% kidney progression reduction) by name.
• Reference the FDA label's four approved indications to counter any "not medically necessary" denial language [1].

The FDA's drug label states that Jardiance is indicated "to reduce the risk of cardiovascular death and hospitalization for heart failure in adults with heart failure" and "to reduce the risk of sustained eGFR decline, end-stage kidney disease, cardiovascular death, and hospitalization for heart failure in adults with CKD at risk of progression" [1]. Anthem medical directors are obligated to review FDA label language in coverage decisions.