Does Anthem Cover Jardiance?
The verdict
Covered on most plans
Anthem (Elevance Health) covers Jardiance for type 2 diabetes, heart failure, and CKD across commercial, ACA, Medicare Advantage, and Medicaid, managed through its CarelonRx PBM. Jardiance is broadly on-formulary across Anthem plans (MMIT: 99.7% commercial, 99.9% Medicare, as of Aug 8, 2025). Commercial and Medicaid plans commonly apply a metformin-first step therapy via CarelonRx. On Medicare, prior authorization is essentially absent and the 2026 IRA MFP of $197 governs cost.
Coverage is set by your specific plan and formulary. This is a research summary — always confirm with Anthem using your member ID.
Medicare vs. commercial coverage
Whether Anthem covers Jardiance depends heavily on which kind of plan you hold. They follow completely different rules — here's each one, side by side.
Medicare
Part D & Advantage plans
Covered on Anthem Medicare Advantage and Part D plans, typically as a Tier 3 preferred brand. Prior authorization and step therapy are essentially nil in Medicare nationally (MMIT: 0% PA, 0.1% step, as of Aug 8, 2025). The 2026 IRA Maximum Fair Price for Jardiance is $197/30-day supply, effective 1/1/2026 — a 66% reduction from the prior $573 list price. The $2,100 Part D out-of-pocket cap applies. As a Part D sponsor, Anthem is legally required to carry Jardiance at the MFP in 2026. Actual copay depends on whether your specific Anthem plan uses a fixed copay or coinsurance — verify in your Evidence of Coverage.
Commercial / Employer
Group & marketplace plans
Covered via CarelonRx across Anthem commercial/employer and ACA plans. MMIT shows 99.7% of commercial plans cover Jardiance nationally. Metformin-first step therapy is common on commercial plans through CarelonRx (MMIT: 38.9% commercial, 27.7% ACA step therapy, as of Aug 8, 2025). Anthem Medicaid managed-care plans cover Jardiance at $0–$10 typical cost-share, with PA and step therapy common (MMIT Medicaid: 25.5% PA, 22.9% step). Anthem operates in many states; verify coverage on the CarelonRx formulary for your specific Anthem plan.
The 2 boxes you must tick to get approved
Commercial plans that will consider Jardiance require prior authorization. Check off what applies to you to see how close you are — this is a guide, not a guarantee of approval.
Meet all 2 and you have a documented case for approval. Missing any one is the most common reason requests are denied.
Your cost, three ways
What Jardiance actually costs you swings enormously depending on how it's covered. Here's the realistic range.
Paying cash
~$600+ retail (pharmacy-variable estimate, brand Jardiance, no generic available)
List price with no coverage — before any manufacturer savings card.
With coverage
Tier 3 cost-share varies by Anthem/CarelonRx plan; ~84% of Medicare Part D patients nationally pay $0–$50/month (Boehringer Ingelheim, manufacturer-reported average, not a guarantee)
Typical monthly copay once prior authorization is approved.
Bridge program
Boehringer Ingelheim savings card ~$10/month for commercially insured (not Medicare/Medicaid); verify acceptance at your pharmacy through CarelonRx
Reduced copay through the assistance program, where eligible.
All figures are estimates — confirm cost-share with Anthem Member Services or CarelonRx. Medicare cost governed by the $197 MFP and $2,100 OOP cap in 2026. Anthem/CarelonRx differs from Aetna/Caremark and UHC/OptumRx — the formulary tools are distinct.
Check YOUR exact coverage in 3 steps
General answers only get you so far. Here's how to confirm your own plan's decision in a few minutes.
- 1
Search for Jardiance on the Anthem or CarelonRx drug list
Log in to the Anthem member portal (anthem.com or elevancehealth.com) and search for Jardiance (empagliflozin) in the prescription drug list. You can also search the CarelonRx formulary directly. Check the tier, any prior-authorization or step-therapy requirement, and your estimated cost-share.
- 2
Document metformin history if on a commercial or Medicaid plan
If your Anthem commercial or Medicaid plan requires metformin-first step therapy, ask your prescribing physician to document your metformin trial (or a medical reason it cannot be used) in the prior-authorization request. Resolving this step early avoids most Jardiance coverage delays.
- 3
Call Anthem pharmacy benefits for plan-specific confirmation
Call the pharmacy benefits number on your Anthem member ID card and ask about Jardiance tier, any PA or step-therapy requirement, and your estimated copay. For Medicare, ask specifically about the 2026 IRA negotiated price and the $2,100 cap.
Options if Anthem won't cover Jardiance
A denial isn't the end of the road. These are the paths people commonly explore next — discuss any of them with your prescriber.
Metformin (generic)
First-line T2D generic, near-universally Tier 1 at ~$4/month. Anthem commercial and Medicaid plans typically require a metformin trial before approving Jardiance — it is the prerequisite step.
Farxiga (dapagliflozin) or generic dapagliflozin
Another SGLT2 in the same class; generic dapagliflozin is now available. Farxiga carries even higher commercial step therapy (MMIT: 45.8%) and a $178.50 2026 MFP. Ask your physician which SGLT2 your Anthem plan prefers.
Januvia (sitagliptin) or generic sitagliptin
DPP-4 inhibitor alternative for T2D. Generic sitagliptin launched May 2026 — significantly lower cash cost than the brand. Different mechanism than SGLT2; discuss with your physician.
These options are listed for information only — your own clinician decides what is appropriate for you.
❓Frequently Asked Questions
On Anthem commercial and Medicaid plans, metformin-first step therapy is common — MMIT data shows 38.9% of commercial plans nationally require it for Jardiance (as of Aug 8, 2025). Anthem's CarelonRx PBM manages this step. On Anthem Medicare Advantage plans, step therapy is essentially absent. If you have a commercial or Medicaid Anthem plan, ask your physician to document metformin history in the prior-authorization request to streamline the process.
Both cover Jardiance broadly, but they use different PBMs: Anthem uses CarelonRx, while Aetna uses CVS Caremark. Both commonly apply metformin-first step therapy on commercial plans and have near-zero Medicare PA. A notable Aetna-specific detail is Farxiga on Tier 2 with a 30-tablet/month Medicare limit; Anthem's specific tier placement for Jardiance should be verified separately on the CarelonRx formulary. The underlying step-therapy rates are similar nationally.
Anthem Medicare Advantage plans must honor the 2026 IRA Maximum Fair Price for Jardiance of $197/30-day supply. Your actual copay depends on whether your specific Anthem Medicare plan uses a fixed copay or coinsurance for Tier 3 drugs. The $2,100 annual out-of-pocket cap limits maximum exposure. Verify your cost-share in your plan's Evidence of Coverage or by calling Anthem pharmacy benefits.
Jardiance has FDA approval for type 2 diabetes, heart failure with reduced ejection fraction, and chronic kidney disease. Anthem generally covers FDA-approved on-label indications. Have your prescribing cardiologist or nephrologist note the specific FDA-approved indication on the prescription or in any prior-authorization request. Coverage for off-label use is not guaranteed — verify with Anthem separately.
CarelonRx is Anthem/Elevance Health's in-house pharmacy benefit manager. It manages the formulary, step-therapy rules, and PA criteria for most Anthem commercial, ACA, and Medicare plans. When searching for Jardiance coverage information, use the CarelonRx formulary tool or the Anthem member portal — both reflect the same underlying formulary. This distinguishes Anthem from Aetna (CVS Caremark) and UnitedHealthcare (OptumRx).
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Read moreThis content is for informational purposes only and does not constitute medical, financial, or insurance advice. Coverage rules, prior-authorization criteria, and copay amounts change frequently and vary by plan, formulary tier, and effective date — always verify current benefits directly with Anthem before making any decision. Consult a licensed healthcare provider and your plan administrator for guidance specific to your situation.