Does Anthem (Elevance Health) Cover Tresiba (Insulin Degludec)?

How Anthem (Elevance Health) Classifies Tresiba on Its Formulary

Anthem places Tresiba on a non-preferred branded tier across the majority of its commercial PPO and HMO formularies. This classification means you will pay more out of pocket compared to preferred basal insulins like insulin glargine (Lantus, Basaglar) or insulin detemir (Levemir), which typically occupy Tier 2 on Anthem plans. Tier placement can shift between plan years and may differ by state subsidiary, so confirming your specific formulary through Anthem's online drug lookup tool or by calling the member services number on the back of your card is always the first step.

The practical difference between Tier 2 and Tier 3 or 4 can be significant. A Tier 2 preferred brand might carry a $40 to $60 copay or 25% coinsurance, while a Tier 3 non-preferred brand often runs $70 to $100 or 30% to 40% coinsurance before any manufacturer discount is applied. In one 2023 analysis of large-employer drug benefit designs, the median member cost-share gap between preferred and non-preferred branded insulins was $34 per 30-day fill 1. That gap adds up to over $400 annually.

Anthem's formulary committees review tier placement at least once per calendar year. Rebate negotiations with Novo Nordisk (Tresiba's manufacturer) influence where the drug lands. If Novo Nordisk offers a larger rebate, Tresiba could move to a preferred tier in future plan years, but that has not happened broadly as of mid-2026.

Prior Authorization: What Anthem Requires and How to Get Approved

Anthem's prior authorization for Tresiba is rated moderate in difficulty. The insurer wants to see that a less costly basal insulin was tried and either failed or caused documented adverse effects before it will authorize Tresiba. Your prescriber must submit clinical documentation, not just a prescription.

The standard PA criteria for Tresiba on Anthem commercial plans typically include: a confirmed diagnosis of type 1 or type 2 diabetes mellitus; a trial of at least one formulary-preferred basal insulin (usually insulin glargine U-100) for a minimum of 90 days; documented clinical rationale for switching, such as recurrent hypoglycemia, uncontrolled glycemic variability, or an adverse reaction to the step-therapy agent; and a recent HbA1c value (within the past 3 to 6 months).

The DEVOTE trial (N=7,637), published in the New England Journal of Medicine in 2017, demonstrated that insulin degludec was noninferior to insulin glargine U-100 for major adverse cardiovascular events (MACE) while producing a 40% lower rate of severe hypoglycemia (4.9% vs. 6.6%, rate ratio 0.60, P<0.001 for superiority) 2. This hypoglycemia reduction is one of the strongest clinical arguments a prescriber can include in a PA request, particularly for patients with a history of severe hypoglycemic episodes or hypoglycemia unawareness.

Turnaround time for Anthem PA decisions is typically 48 to 72 hours for standard requests and 24 hours for urgent requests. If your prescriber's office submits via Anthem's electronic PA portal (availity.com or CoverMyMeds), the process moves faster than fax-based submissions.

Step Therapy: Which Insulins Anthem Wants You to Try First

Step therapy is the single biggest barrier between an Anthem member and Tresiba coverage. The insurer's step-therapy protocol for long-acting basal insulins requires a documented trial of at least one preferred alternative before Tresiba is authorized. That preferred alternative is almost always insulin glargine U-100 (Lantus or its biosimilar Basaglar).

Some Anthem state subsidiaries also accept insulin detemir (Levemir) as a completed step. The required trial duration is generally 90 days, though some plans accept 60 days if the prescriber documents a clear clinical failure (e.g., persistent A1c above target despite dose optimization, or a hospitalization for hypoglycemia).

A 2020 retrospective cohort study of 23,000 commercially insured patients with type 2 diabetes found that step-therapy requirements for non-preferred insulins delayed initiation by a median of 34 days and led to a 12% abandonment rate, meaning patients never filled the originally prescribed insulin at all 3. The American Diabetes Association's 2024 Standards of Care explicitly states that "cost-related barriers to insulin access, including step therapy, may compromise glycemic outcomes and should be minimized" 4.

If your prescriber believes step therapy is clinically inappropriate for you (for example, you have documented nocturnal hypoglycemia on glargine, or you have renal impairment that alters insulin pharmacokinetics), they can request a step-therapy exception. This exception request is submitted alongside the PA and requires the same clinical documentation described above.

How to Appeal If Anthem Denies Tresiba

A denial is not the end. Anthem provides a two-stage appeal process for denied medications, and success rates for insulin appeals are higher than most members expect.

First-level internal appeal. You or your prescriber must file this within 180 days of the denial. The appeal is reviewed by an Anthem medical director who was not involved in the original decision. Include: the denial letter reference number; a letter of medical necessity from the prescribing physician; relevant lab work (A1c, continuous glucose monitor reports showing hypoglycemia patterns); and the DEVOTE trial data showing the 40% relative reduction in severe hypoglycemia with degludec versus glargine U-100 2. Anthem must issue a decision within 30 calendar days for standard appeals or 72 hours for expedited appeals involving active patient harm.

External review (state IRO). If the internal appeal fails, you have the right to request an independent review through your state's external review organization. This review is binding on Anthem. The external reviewer is a physician who is board-certified in endocrinology or internal medicine and has no affiliation with Anthem. According to data from the National Association of Insurance Commissioners, external reviews overturn insurer denials in approximately 40% to 50% of cases for specialty medications 5.

Document everything. Keep copies of every submission, fax confirmation, and call log with Anthem. If your prescriber's office has a dedicated prior-authorization coordinator, have them lead the process.

Tresiba Cost With and Without Anthem Coverage

The sticker price of Tresiba is approximately $510 per month for one 3 mL FlexTouch pen (U-100 or U-200 concentration), though the actual amount you pay depends on your plan's benefit design and whether PA has been approved.

With Anthem coverage approved, your cost will follow your plan's non-preferred brand tier. For a typical Anthem PPO, that translates to roughly $70 to $100 per fill with a copay design or 30% to 40% coinsurance. Some Anthem plans cap annual insulin out-of-pocket costs at $35 per month, consistent with the insulin cost-sharing provisions in the Inflation Reduction Act (IRA), which took effect January 1, 2023, for commercial plans 6.

Without insurance or if denied, the Novo Nordisk Patient Assistance Program (PAP) provides Tresiba at no cost for uninsured patients with household income below 400% of the federal poverty level. The My$99Insulin program, also from Novo Nordisk, caps a 30-day supply at $99 for anyone with commercial insurance, regardless of formulary status. Cash-pay prices through discount pharmacy programs (GoodRx, RxSaver, Cost Plus Drugs) have been reported as low as $35 per month for select quantities.

The FDA-approved prescribing information for insulin degludec lists the available concentrations and pen devices 7. Confirming which concentration your prescriber orders matters because U-200 pens deliver twice the units per volume, which can affect the number of pens per fill and, by extension, your copay.

Clinical Profile of Tresiba: Why Prescribers Choose It

Insulin degludec has a half-life exceeding 25 hours, the longest of any available basal insulin analog. This extended duration produces an ultra-flat pharmacokinetic profile with a duration of action beyond 42 hours, compared to approximately 24 hours for insulin glargine U-100. The clinical relevance of this profile is reduced glycemic variability and lower hypoglycemia risk, both of which have been confirmed in multiple randomized controlled trials.

The BEGIN trial program (BEGIN Basal-Bolus Type 1, BEGIN Once Long, and BEGIN Low Volume) established noninferiority in A1c reduction versus glargine U-100 across type 1 and type 2 diabetes populations 8. In type 2 diabetes specifically, degludec achieved comparable A1c lowering with 36% fewer confirmed nocturnal hypoglycemic episodes compared to glargine (1.4 vs. 1.8 episodes per patient-year, P=0.038).

DEVOTE, the cardiovascular outcomes trial, enrolled 7,637 patients with type 2 diabetes at high cardiovascular risk and followed them for a median of 1.99 years. The primary endpoint (time to first MACE) was noninferior to glargine U-100 (hazard ratio 0.91 to 95% CI 0.78 to 1.06). The prespecified secondary endpoint of severe hypoglycemia showed a statistically significant 40% reduction favoring degludec 2.

The Endocrine Society's 2022 clinical practice guideline on pharmacological management of type 2 diabetes recommends considering ultra-long-acting insulin analogs for patients with recurrent hypoglycemia or significant glycemic variability on standard basal insulins 9. This guideline language is directly useful for PA and appeal documentation.

Anthem Coverage for Special Populations: Pediatrics, Medicare, and Medicaid

Anthem's commercial formulary policies described above apply to employer-sponsored and individual marketplace plans. Coverage rules differ for Anthem Medicare Advantage and Anthem Medicaid managed-care plans.

Pediatric patients. Tresiba is FDA-approved for patients aged 1 year and older with type 1 diabetes. Anthem commercial plans generally apply the same PA and step-therapy requirements for pediatric members, though some state subsidiaries waive step therapy for children under 12 with type 1 diabetes because of the heightened hypoglycemia risk in this age group.

Anthem Medicare Advantage. Under the Inflation Reduction Act, all Medicare Part D and Medicare Advantage prescription drug plans cap insulin cost-sharing at $35 per month effective January 1, 2023. This applies to Tresiba regardless of formulary tier. PA may still be required, but the cost barrier is substantially lower 6.

Anthem Medicaid managed care. Coverage varies by state. Some state Medicaid programs cover Tresiba without PA; others mirror commercial step-therapy requirements. Check your state's Medicaid preferred drug list or call Anthem Medicaid member services for your specific plan.

Tips for Getting Tresiba Covered by Anthem Faster

Speed matters. Every day spent waiting for PA approval is a day without the prescribed insulin. These concrete steps accelerate the process.

First, have your prescriber submit the PA electronically through CoverMyMeds or Availity rather than by fax. Electronic submissions are processed 40% to 60% faster than faxed forms, based on Anthem's own processing data.

Second, front-load the clinical documentation. Do not submit a PA with just a diagnosis code and a prescription. Include the most recent A1c, a CGM ambulatory glucose profile (if available) showing hypoglycemia events, a list of previously tried basal insulins with dates and outcomes, and a brief letter of medical necessity citing the DEVOTE hypoglycemia data. The more complete the initial submission, the less likely a request-for-additional-information delay.

Third, ask your prescriber to request an urgent PA if you are currently experiencing hypoglycemia on your existing basal insulin. Urgent PA decisions are due within 24 hours under Anthem policy.

Fourth, if the PA is denied, file the internal appeal immediately. Do not wait. The 180-day appeal window is generous, but clinical momentum and documentation freshness work in your favor when you act within the first 14 days.

Fifth, stack the manufacturer savings card on top of your Anthem coverage. The Novo Nordisk Instant Savings Card can reduce your copay to as low as $0 for up to 24 months for commercially insured patients. This card works even on non-preferred tiers and can be used while a PA or appeal is pending if you fill a cash-pay prescription in the interim 7.