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

Tresiba (insulin degludec) is an ultra-long-acting basal insulin developed by Novo Nordisk that has received FDA approval for managing blood glucose levels in both type 1 and type 2 diabetes across all age groups starting from 1 year old. This basal insulin comes in U-100 and U-200 formulations delivered via pen devices, distinguishing it from rapid-acting and premixed insulin products.

Anthem is not one plan. Elevance Health operates Anthem-branded commercial, Medicare Advantage, and Medicaid managed-care plans across many states, and each state subsidiary and each employer or marketplace product can run its own formulary. Because of that, there is no single, verifiable "Anthem formulary rule" for Tresiba that applies to every member. What can be said with confidence is the general pattern: commercial insurers typically place a higher-cost basal insulin analog like Tresiba behind prior authorization and step therapy when lower-cost basal insulins (insulin glargine products such as Lantus or Basaglar, or insulin detemir/Levemir) are available on a preferred tier. Whether that pattern applies to your specific Anthem plan, and what the exact criteria and cost-share are, has to be confirmed against your plan's own documents.

The direct answer, with its boundary: most Anthem commercial plans are likely to require prior authorization and a documented trial of a preferred basal insulin before covering Tresiba on a non-preferred branded tier, but the specific tier, dollar copay, and step-therapy duration vary by state and plan and are not published in a single national Anthem policy that can be cited here. Confirm your plan's actual rules through Anthem's member portal, the Availity provider portal, or the number on your insurance card before assuming any number in this article applies to you.

What "covered" is likely to mean on your plan

If Tresiba is covered at all, it is almost always covered as a non-preferred brand rather than a preferred brand, because cheaper basal insulin analogs exist and PBMs generally steer members toward the lowest-net-cost option first. That usually means:

• A higher copay or coinsurance than a preferred basal insulin
• A prior authorization requirement
• A step-therapy requirement (trial of a preferred basal insulin first)

These are standard utilization-management tools used across the health insurance industry, not something unique to Anthem. The exact tier number (Tier 2, 3, or 4), the exact copay, and whether step therapy is waived for any group of patients depends on the specific certificate of coverage for your plan. Anthem's online formulary lookup tool (accessed with your member ID) or a call to member services is the only reliable way to get your plan's actual numbers.

Prior authorization: the general pattern and how to build a strong request

Insurers that require prior authorization for a non-preferred basal insulin generally want documentation that a preferred option was tried and did not work, or caused a problem. A typical PA package that prescribers submit for a step-up to an ultra-long-acting basal insulin includes:

• Confirmed diagnosis (type 1 or type 2 diabetes)
• Documentation of a trial of a preferred basal insulin, usually insulin glargine U-100, for some minimum period defined by the plan
• Clinical rationale for switching, such as recurrent hypoglycemia, glycemic variability, or an adverse reaction
• A recent HbA1c value

Clinically, insulin degludec's pharmacology supports the hypoglycemia-related rationale that prescribers often cite. Degludec has a longer duration of action and a flatter time-action profile than insulin glargine U-100, which has been associated with less nocturnal and severe hypoglycemia in randomized trials comparing degludec to glargine in people with type 2 diabetes at elevated cardiovascular risk. If your prescriber is building a medical-necessity case around hypoglycemia history, this class of trial evidence (rather than a specific number pulled from a single citation) is the relevant clinical anchor, and the exact trial and its effect size should be verified against the primary publication before being quoted in an appeal letter, since a wrong or garbled citation can weaken rather than strengthen a request.

Processing timelines for standard versus urgent PA requests, and whether electronic submission is faster than fax, vary by plan and are not something this article can state as a fixed Anthem-wide number. Ask your prescriber's office what turnaround Anthem is currently quoting for your specific plan.

Step therapy: what it is and when an exception may be reasonable

Step therapy means the plan wants proof that a preferred, usually cheaper, basal insulin was tried first. For basal insulins, the preferred step is almost always a glargine product. If you have a clinical reason step therapy should not apply to you, for example a documented history of nocturnal hypoglycemia on glargine, or renal impairment that changes insulin clearance and hypoglycemia risk, your prescriber can request a step-therapy exception alongside the PA. This requires the same kind of clinical documentation described above: labs, hypoglycemia events, and a clear statement of why the preferred agent is not appropriate for you specifically.

Cost-related access barriers, including step therapy, are a recognized concern in diabetes care generally. The American Diabetes Association's Standards of Care addresses the risk that cost and utilization-management barriers can compromise glycemic control, and that concern is a reasonable general point to raise in a step-therapy exception letter, though the exact wording of any guideline text should be checked against the current Standards of Care document rather than quoted from memory.

If Anthem denies the claim: your appeal rights

Regardless of the exact internal Anthem process, U.S. insurance regulation generally gives members two levels of recourse after a denial:

1. Internal appeal with the plan. You or your prescriber can ask the plan to reconsider, submitting a letter of medical necessity, lab results, and any supporting clinical documentation. Plans are generally required to respond within a defined number of days for standard appeals and much faster for urgent appeals involving ongoing harm, but the exact day counts are set by your plan documents and state law, not by a single number that applies everywhere.
2. External review. If the internal appeal fails, most states give you the right to an independent external review by a reviewer with no relationship to the insurer. That decision is generally binding on the plan. How often external reviews overturn insurer denials for a specific drug class is not something this article can state as a verified statistic without a specific, checked source, so avoid repeating a precise overturn percentage in an appeal letter unless it is sourced to your state's insurance department data.

Keep your own paper trail: the denial letter and its reference number, every fax confirmation, and a log of calls with dates and representative names. If your prescriber's office has a staff member who specializes in prior authorizations, ask them to lead the appeal.

Cost while you wait, or if you are denied

Tresiba's list price and any specific cash-pay number change over time and by pharmacy, so treat any dollar figure you see as a snapshot that needs to be reconfirmed at the pharmacy counter or on GoodRx-type tools before you rely on it.

Two cost protections are well established and dated:

• Under the Inflation Reduction Act, Medicare Part D and Medicare Advantage prescription drug plans have capped insulin cost-sharing at $35 per month per covered insulin product since January 1, 2023. This applies to Tresiba on Anthem Medicare Advantage plans regardless of formulary tier, though prior authorization may still apply (CMS, Inflation Reduction Act and Medicare).
• The IRA's insulin cap does not automatically extend to employer-sponsored commercial plans; some commercial plans have voluntarily adopted a similar $35 cap, but this is plan-specific and must be confirmed in your certificate of coverage.

Novo Nordisk has historically offered patient assistance for uninsured patients and a co-pay savings card for commercially insured patients that can reduce out-of-pocket cost, and the company has also run a program capping certain insulin fills at a set monthly price. Because manufacturer program terms, income thresholds, and expiration dates change, confirm current eligibility and dollar caps directly on Novo Nordisk's patient support site rather than relying on a fixed figure here. A savings card generally cannot be used with Medicare or Medicaid.

Special populations

Pediatric patients. Tresiba's FDA-approved indication includes children age 1 year and older with type 1 diabetes. Whether a given Anthem state plan waives step therapy for young children with type 1 diabetes because of hypoglycemia risk is a plan-specific policy decision, not a universal rule, and should be confirmed with your child's plan.

Medicare Advantage. The $35 monthly insulin cap described above applies here. Prior authorization may still be required even though the cost-sharing cap removes most of the financial barrier.

Medicaid managed care. Anthem Medicaid coverage rules are set state by state and can differ substantially from commercial rules, including whether prior authorization applies at all. Check your state's Medicaid preferred drug list directly.

What is established, what is plausible, and what is not established

Established: Tresiba (insulin degludec) is FDA-approved for type 1 and type 2 diabetes in adults and children age 1 year and older. Medicare Part D and Medicare Advantage plans, including Anthem's, are subject to the federal $35 per month insulin cost-sharing cap that took effect January 1, 2023. Commercial insurers, as a general industry pattern, place non-preferred branded insulins behind prior authorization and step therapy.

Plausible but plan-dependent: the specific formulary tier, copay amount, step-therapy duration, and PA turnaround time for Tresiba on any individual Anthem commercial plan. These vary by state subsidiary and by employer group and are not published as one nationwide Anthem policy.

Not established from the sources available for this article: a specific percentage of external-review appeals overturned for Tresiba denials, a specific dollar gap between preferred and non-preferred insulin copays on Anthem plans, and a specific Anthem-quoted PA processing time in hours. Numbers of this kind should not be repeated in an appeal letter or a cost conversation unless they are freshly confirmed against your own plan documents or a dated primary source.

Decision framework: getting from "denied" or "unsure" to a filled prescription

Use this sequence rather than assuming a single fixed rule applies to your plan.

Step 1: Confirm the actual rule for your plan. Log into your Anthem member portal or call the number on your card and ask three specific questions: what tier is Tresiba on, is prior authorization required, and is step therapy required. Write down the answer and the date you were told it, since formularies change by plan year.

Step 2: If step therapy is required, check whether you already meet it. If you have already tried and failed a glargine or detemir product, ask your prescriber to document the trial dates, dose, and reason it did not work (uncontrolled A1c, nocturnal hypoglycemia, an allergic reaction, etc.). If you have never tried a preferred basal insulin and have no clinical contraindication to trying one, expect the plan to require that trial first.

Step 3: If there is a clinical reason to skip the step, request an exception rather than appealing after the fact. A step-therapy exception submitted with the initial PA, supported by hypoglycemia data or a documented contraindication, is generally faster than fighting a denial after it happens.

Step 4: If denied, file the internal appeal immediately, not at the end of the window. Even though the appeal window is typically measured in months, submitting within the first two weeks keeps your labs and CGM data current and keeps clinical momentum with your prescriber's office.

Step 5: If the internal appeal fails, request external review. This is a right created by state and federal law, independent of Anthem's internal process, and the decision is binding on the plan.

Step 6: Bridge the gap while any of this is pending. Ask the pharmacy about a manufacturer savings card or patient assistance program so you are not without basal insulin during the PA or appeal process. Confirm current terms before counting on a specific price, since these programs change.

Exception to the whole sequence: if you are experiencing symptoms of severe hypoglycemia, ketoacidosis, or are otherwise clinically unstable, this is an urgent medical situation, not a coverage question. Seek urgent or emergency care first and sort out insurance afterward.