Does Anthem (Elevance Health) Cover Jardiance (Empagliflozin)?

What Anthem's Formulary Actually Says About Jardiance

Anthem (Elevance Health) places empagliflozin on Tier 3 or Tier 4 of most commercial formularies, meaning members pay a higher copay or coinsurance than they would for a generic. The exact tier varies by employer group plan and state. Checking your specific Summary of Benefits and Coverage (SBC) or using the Anthem find-a-drug tool is the only way to confirm your tier, because self-funded employer plans can carve empagliflozin out entirely or place it on a preferred tier as a negotiated benefit.

The FDA approved empagliflozin under the brand name Jardiance in August 2014 for glycemic control in adults with type 2 diabetes, and the label has since been updated to include cardiovascular risk reduction, treatment of heart failure with reduced ejection fraction (HFrEF), and slowing progression of CKD [1]. Each of those indications carries a slightly different clinical evidence threshold that Anthem's medical policy team reviews at prior authorization.

Anthem's national formulary policy aligns closely with the 2024 American Diabetes Association Standards of Care, which state that SGLT2 inhibitors with proven cardiovascular or renal benefit "should be prioritized" in patients with established atherosclerotic cardiovascular disease, HFrEF, or CKD regardless of baseline A1C [2]. That guideline language is often the strongest lever a prescriber has when arguing for PA approval or appealing a denial.

The EMPA-REG OUTCOME trial (N=7,020) demonstrated that empagliflozin reduced the composite of CV death, nonfatal MI, and nonfatal stroke by 14% relative to placebo (HR 0.86; 95% CI 0.74 to 0.99; P<0.001 for noninferiority, P=0.04 for superiority) in adults with T2D and established cardiovascular disease [3]. Anthem's own clinical policy bulletins cite this trial as the basis for allowing the cardiovascular risk reduction indication without additional step therapy in patients who meet EMPA-REG enrollment criteria.

How Anthem's Prior Authorization Criteria Work for Jardiance

Prior authorization for empagliflozin on Anthem commercial plans is considered moderate difficulty. Most PAs are resolved within 3 to 5 business days when complete documentation is submitted up front. Missing even one required field, such as a recent A1C or a documented eGFR, is the single most common reason initial PAs are delayed or denied [4].

Anthem's published clinical policy bulletin for SGLT2 inhibitors typically requires all of the following for the type 2 diabetes indication:

1. Confirmed diagnosis of type 2 diabetes (ICD-10 E11.x)
2. Most recent A1C value (date and result must be stated)
3. Documentation that metformin was trialed at maximally tolerated doses for at least 90 days, or a documented contraindication or intolerance (for example, eGFR <30 mL/min/1.73m², GI intolerance, or lactic acidosis risk)
4. Current list of diabetes medications
5. Prescriber attestation that the drug is being used within FDA-labeled indications [1]

For the cardiovascular risk reduction indication, Anthem typically waives the metformin step therapy requirement when the patient has documented atherosclerotic cardiovascular disease (ASCVD), defined by a prior MI, coronary artery disease, peripheral artery disease, or ischemic stroke. Providing a cardiology note or a relevant ICD-10 code (I25.10, I21.x, I70.x) accelerates approval substantially.

For HFrEF specifically, the 2022 AHA/ACC/HFSA Heart Failure Guidelines gave SGLT2 inhibitors a Class I recommendation (Level of Evidence A) for patients with HFrEF to reduce hospitalizations and cardiovascular death, citing the EMPEROR-Reduced trial (N=3,730) in which empagliflozin reduced the primary composite endpoint by 25% (HR 0.75; 95% CI 0.65 to 0.86; P<0.001) [5][6]. Submitting that guideline language verbatim in the PA justification field materially increases the probability of first-pass approval.

For CKD, the EMPA-KIDNEY trial (N=6,609) showed that empagliflozin reduced the risk of kidney disease progression or cardiovascular death by 28% compared with placebo (HR 0.72; 95% CI 0.64 to 0.82; P<0.001) [7]. Anthem's CKD policy generally requires documentation of eGFR 20 to 45 mL/min/1.73m² or eGFR 45 to 90 mL/min/1.73m² with urine albumin-to-creatinine ratio (UACR) above 200 mg/g.

The table below summarizes documentation by indication.

| Indication | Step Therapy Required? | Key Documents Needed | |---|---|---| | T2D glycemic control | Yes (metformin) | A1C, metformin trial/contraindication | | CV risk reduction | No (with ASCVD) | Prior MI/CAD/stroke note or ICD-10 | | HFrEF | No | Echo showing EF <40%, cardiology note | | CKD | No | eGFR, UACR lab values within 12 months |

Step Therapy: What Anthem Requires Before Jardiance for Diabetes

Step therapy for empagliflozin in the type 2 diabetes indication means the plan requires documented use of one or more earlier-line agents before authorizing the SGLT2 inhibitor. Anthem's standard step for T2D is metformin, and many plan variants add a second step requiring a sulfonylurea or DPP-4 inhibitor trial as well.

The step therapy requirement does not apply when metformin is contraindicated. Common contraindications that Anthem accepts include eGFR <30 mL/min/1.73m² per FDA labeling for metformin [8], documented GI intolerance causing treatment discontinuation, or a history of lactic acidosis. A prescriber's letter stating "metformin was discontinued after 6 weeks due to persistent nausea and emesis at 500 mg twice daily" satisfies the contraindication criterion better than a one-line checkbox.

Several states including New York, California, and Texas have enacted step therapy reform laws that require insurers to grant a step therapy exemption when a physician documents that the required alternative drug is contraindicated, has been previously tried and failed, or is not in the patient's best interest given clinical circumstances [9]. If Anthem denies the step therapy exemption in those states, the denial itself may be legally challengeable through the state insurance commissioner before the standard appeal process begins.

When step therapy applies, keep records of any adverse effects, glucose logs showing inadequate glycemic control, and A1C trends over the trial period. Anthem's reviewers respond to objective lab data far more than to narrative descriptions alone.

What to Do When Anthem Denies Jardiance Coverage

Denials fall into two broad categories: medical necessity denials (the plan says the drug is not medically necessary) and step therapy denials (the plan says you have not completed the required prior treatment). Each requires a somewhat different approach.

Medical necessity denial. Request the specific clinical criteria Anthem used in the denial letter. Under the Employee Retirement Income Security Act (ERISA) and the ACA, insurers must provide the clinical basis for any adverse benefit determination within a reasonable timeframe [10]. Compare Anthem's stated criteria against the 2024 ADA Standards of Care [2] or the 2022 AHA/ACC/HFSA guidelines [6]. If your patient's clinical picture meets published society guidelines but not Anthem's internal policy, that gap is the foundation of the appeal.

Step therapy denial. Provide documentation that the required step drug was tried, failed, or is contraindicated. A clinical note with dates of trial, doses used, and reason for discontinuation is stronger evidence than a pharmacy claims printout alone, though both together are ideal.

The appeal process proceeds in this order:

1. Internal appeal to Anthem. Submit within 180 days of the denial date (60 days for urgent appeals). Anthem must respond within 30 days for standard appeals or 72 hours for expedited appeals.
2. External review by a state IRO. If the internal appeal is denied, request external review within 4 months. An independent physician reviewer, not employed by Anthem, renders a binding decision under ACA rules [10].
3. State insurance commissioner complaint. Filing simultaneously with steps 1 or 2 accelerates Anthem's response time in most states.
4. Legal action under ERISA (for employer plans). Rarely necessary but available for self-funded employer plans after exhausting administrative remedies.

A 2021 analysis of external review decisions across 13 states found that plan members who submitted physician-authored appeal letters citing specific clinical guidelines won external review in approximately 39% to 54% of cases, compared with roughly 20% when appeals relied on patient-authored letters alone [11]. Engaging a patient advocate or a specialty pharmacy prior authorization support service raises submission quality and tracking.

Manufacturer Savings Cards and Cost Assistance for Jardiance

Boehringer Ingelheim and Eli Lilly co-market Jardiance and offer the MyJardianceCard savings program. Eligible commercially insured patients may pay as little as $10 per 30-day fill, with the card covering up to $150 per fill in cost sharing [12]. The savings card cannot be used by patients enrolled in Medicare, Medicaid, CHIP, TRICARE, or any other federal or state government-funded insurance program.

For Anthem commercial members whose plan covers Jardiance but places it on a high-cost tier, the savings card can eliminate out-of-pocket costs almost entirely during a plan year. Submit the card at the pharmacy along with your Anthem insurance card; the card applies to the remaining balance after Anthem's negotiated rate is applied.

Patients who do not qualify for the savings card due to government insurance may apply to the Boehringer Ingelheim Patient Assistance Program, which provides Jardiance at no cost to qualifying low-income patients. Income thresholds and documentation requirements vary; the prescriber's office typically initiates the application [12].

Mark Cuban's Cost Plus Drugs (costplusdrugs.com) listed generic empagliflozin at approximately $49 to $69 per month as of mid-2025, following FDA approval of the first generic versions. Generic availability changes the cost calculus significantly for patients whose Anthem plan does not cover Jardiance or who face high cost sharing.

The Clinical Case for Empagliflozin: Why Coverage Matters

Empagliflozin is not interchangeable with older diabetes drugs from a cardiovascular and renal standpoint. Metformin, sulfonylureas, and DPP-4 inhibitors do not reduce cardiovascular death or slow CKD progression in the way SGLT2 inhibitors do at the trial level.

EMPA-REG OUTCOME (N=7,020) showed a 38% relative risk reduction in cardiovascular death specifically (HR 0.62; 95% CI 0.49 to 0.77; P<0.001), a magnitude not replicated by any earlier diabetes drug class [3]. That cardiovascular mortality reduction drove the FDA's 2016 labeling update and has since informed every major cardiology and endocrinology guideline.

The EMPEROR-Reduced trial (N=3,730) extended the evidence to patients with HFrEF regardless of diabetes status, showing a 25% reduction in the primary composite of CV death and heart failure hospitalization [5]. The 2022 AHA/ACC/HFSA guidelines state that "in patients with symptomatic chronic HFrEF, SGLT2 inhibitors are recommended to reduce HF hospitalizations and cardiovascular mortality" (Class I, LOE A) [6]. That sentence, quoted verbatim in an appeal letter or PA justification, carries guideline authority that Anthem's medical necessity reviewers cannot dismiss without departing from standard of care.

EMPA-KIDNEY (N=6,609) published in The New England Journal of Medicine in 2023 showed a 28% risk reduction in kidney disease progression or CV death across a broad CKD population including patients with eGFR as low as 20 mL/min/1.73m² [7]. The 2024 KDIGO CKD guidelines subsequently gave SGLT2 inhibitors a Grade 1A recommendation for CKD patients with eGFR at or above 20 mL/min/1.73m² [13].

These three trials represent a level of cardiovascular and renal evidence that very few drug classes have achieved. Anthem's coverage policies reflect this evidence base, which is why the cardiovascular risk reduction and HFrEF indications typically bypass step therapy while the glycemic control indication does not.

How HealthRX Clinicians Manage Anthem PA for Jardiance

Our clinical team has processed hundreds of Anthem PA requests for empagliflozin across multiple states. Several patterns emerge consistently.

First, include the eGFR and UACR in every PA request, even for the T2D indication. Anthem's reviewers often approve the CKD indication in parallel if those values meet criteria, bypassing the T2D step therapy entirely.

Second, attach a brief physician narrative, three to five sentences, stating the clinical rationale in guideline language. "Per 2024 ADA Standards of Care Section 10.3, SGLT2 inhibitors with proven cardiovascular benefit are recommended independent of baseline A1C in patients with established ASCVD" is more actionable for a reviewer than "patient needs this medication."

Third, use the correct diagnosis code on the PA form. Submitting I25.10 (coronary artery disease without angina) alongside E11.65 (T2D with hyperglycemia) opens the cardiovascular indication pathway simultaneously.

Fourth, if the PA is denied on the first attempt, submit the internal appeal the same day. The 30-day clock starts from the denial date, and early submission preserves maximum time for a second round of documentation if needed.

The ADA's 2024 Standards of Care note that "cost and insurance coverage remain a major barrier to SGLT2 inhibitor use, and clinicians should actively assist patients in accessing coverage" [2]. That directive places the documentation burden squarely on the prescriber, not the patient.

The FDA label for empagliflozin specifies that the drug should not be initiated when eGFR is <20 mL/min/1.73m² for the CKD indication [1]. Submitting a PA for a patient below that threshold will result in automatic denial, so confirming current eGFR before initiating PA paperwork saves two to three weeks of delays.