Farxiga Medicaid Coverage by State Tier

What Farxiga Is and Why Coverage Tier Matters

Farxiga (dapagliflozin) is an oral sodium-glucose cotransporter-2 (SGLT2) inhibitor manufactured by AstraZeneca. The FDA first approved it in January 2014 for type 2 diabetes (T2D) glycemic management, then expanded the label in May 2020 for heart failure with reduced ejection fraction (HFrEF), and again in April 2021 for chronic kidney disease (CKD) in adults. [1, 2]

Coverage tier determines what you pay at the pharmacy counter. A preferred brand (Tier 2) co-pay on Medicaid is federally capped at $4 per fill; a non-preferred brand (Tier 3 or higher) cap rises to $8. In managed Medicaid plans that operate like commercial formularies, non-preferred tiers can carry co-pays of $20, $75 depending on the plan contract. The difference between preferred and non-preferred status on a 90-day supply adds up to several hundred dollars per year for Medicaid patients with modest incomes.

Why Dapagliflozin Is Frequently Non-Preferred

State Medicaid programs negotiate supplemental rebates with manufacturers. SGLT2 inhibitors as a class often sit on non-preferred tiers because multiple manufacturers compete for preferred placement, and rebate negotiations are annual. The Medicaid Drug Rebate Program (MDRP), governed by 42 U.S.C. § 1396r-8, requires manufacturers to pay a basic rebate of 23.1% of average manufacturer price (AMP) for brand drugs, but supplemental rebates above that floor are negotiated state by state. [3]

The HFrEF and CKD Carve-Out

Several states have created clinical exception pathways that bypass standard step therapy for HFrEF and CKD indications. This matters because the DAPA-HF trial (N=4,744) showed dapagliflozin 10 mg reduced the composite of worsening heart failure or cardiovascular death by 26% versus placebo (hazard ratio 0.74; 95% CI 0.65 to 0.83; P<0.001). [4] The DAPA-CKD trial (N=4,304) showed a 39% reduction in the composite of sustained eGFR decline, ESRD, or renal/cardiovascular death (HR 0.61; 95% CI 0.51 to 0.72; P<0.001). [5] Prescribers who document these specific diagnoses often find PA approval faster than for T2D alone.

Medicaid Tier Classification by State Region

Every state Medicaid program publishes a Preferred Drug List (PDL). Because fee-for-service (FFS) Medicaid and managed care organization (MCO) formularies within the same state can differ, the table below reflects the dominant FFS PDL status as of mid-2025. Individual MCO plans within a state may place dapagliflozin on a more or less restrictive tier. Always verify with the specific MCO's current formulary before prescribing or counseling a patient.

Northeast and Mid-Atlantic States

States in this region (Connecticut, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, and D.C.) generally operate large managed Medicaid programs. New York's Medicaid Preferred Drug Program lists dapagliflozin as non-preferred for T2D but has granted preferred status on several MCO contracts for the HFrEF indication following the 2020 FDA approval. Massachusetts MassHealth places it as non-preferred brand with PA required for T2D; the PA criteria align with the ADA's Standards of Care guidance that SGLT2 inhibitors are recommended for patients with T2D and established CVD, HFrEF, or CKD. [6] Pennsylvania Medicaid requires step therapy through metformin and one other agent before authorizing dapagliflozin for T2D.

Southeast and Gulf Coast States

Florida, Georgia, Alabama, Mississippi, Louisiana, Tennessee, South Carolina, and North Carolina all use MCO-dominant Medicaid structures. Florida Medicaid's PDL designates dapagliflozin non-preferred with PA for T2D and preferred-with-PA for CKD on most MCO contracts. Georgia Medicaid requires PA with documentation of A1C above 7.5% and prior metformin failure for the T2D indication. Louisiana Medicaid has historically been one of the more restrictive states for brand SGLT2 inhibitors, requiring trial of empagliflozin (if preferred in a given contract period) before authorizing dapagliflozin.

Midwest States

Illinois, Michigan, Ohio, Indiana, Wisconsin, Minnesota, Iowa, Missouri, and Kansas Medicaid programs vary considerably. Michigan Medicaid (Michigan Department of Health and Human Services) lists dapagliflozin as non-preferred with PA; the PA form requires documented eGFR and urine albumin-to-creatinine ratio (UACR) for the CKD pathway, consistent with KDIGO 2022 CKD guidelines. [7] Minnesota Medicaid has a class-preferred SGLT2 policy where either empagliflozin or dapagliflozin can be preferred depending on rebate cycles, making it worth checking quarterly.

West Coast and Mountain States

California Medi-Cal operates the largest state Medicaid program by enrollment (approximately 14.5 million members as of 2025). Medi-Cal's Statewide PDL lists dapagliflozin as non-preferred for T2D and non-preferred for HFrEF; however, the CKD indication gained preferred status on several Medi-Cal managed care contracts in 2023 following KDIGO guideline updates. [7] Washington and Oregon both run Coordinated Care Organizations; Oregon's Medicaid PDL requires PA for any brand SGLT2 inhibitor. Colorado and Arizona Medicaid programs similarly require PA and step therapy for T2D but allow expedited PA for HFrEF and CKD when the prescriber submits LVEF documentation or eGFR below 45 mL/min/1.73 m².

Texas and Large Managed-Medicaid States

Texas Medicaid (HHSC) uses four MCO plans statewide. Dapagliflozin sits as non-preferred on all four current contracts for T2D, but PA approval rates are high when prescribers document UACR above 300 mg/g and eGFR 25 to 75 mL/min/1.73 m². The CREDENCE trial (N=4,401, canagliflozin) and DAPA-CKD data together informed the ADA 2024 Standards of Care recommendation that SGLT2 inhibitors be used in T2D with CKD regardless of A1C. [6, 8]

Prior Authorization: What Prescribers Need to Submit

Most PA denials for dapagliflozin are overturned on appeal when documentation is complete. The most common reasons for initial denial are missing lab values and failure to document a previous trial of a preferred agent.

Required Documentation for T2D PA

A complete PA submission for T2D typically includes: current A1C (drawn within 90 days), documentation of metformin trial or contraindication, body weight and BMI, and ICD-10 code E11.x. Some states also require documentation of cardiovascular risk stratification. The ACC/AHA 2023 heart failure guidelines give a Class I recommendation to SGLT2 inhibitors in HFrEF patients regardless of T2D status. [9]

Required Documentation for HFrEF PA

For the HFrEF indication, submit: echocardiographic LVEF below 40%, current NYHA functional class, and documentation of guideline-directed medical therapy (GDMT) including ACE inhibitor/ARB/ARNI and beta-blocker. The EMPEROR-Reduced trial (N=3,730, empagliflozin) and DAPA-HF together anchored the Class I guideline recommendation for SGLT2 inhibitors in HFrEF. [4, 10]

Required Documentation for CKD PA

CKD PA submissions need: eGFR (within 6 months), UACR (within 6 months), ICD-10 code N18.x, and confirmation that the patient is on maximally tolerated renin-angiotensin system (RAS) blockade. The DAPA-CKD trial enrolled patients with eGFR 25 to 75 mL/min/1.73 m² and UACR 200 to 5,000 mg/g; documenting values within those ranges strengthens the PA case. [5]

PA Appeal Strategy

If a PA is denied, the first step is to request the specific denial reason in writing. Forty-two states now require Medicaid MCOs to provide a written clinical rationale within 72 hours of a denial. Attach the relevant trial citations (DAPA-HF [4] or DAPA-CKD [5]) directly to the appeal. A 2022 JAMA Internal Medicine analysis found that physician-led appeals of Medicaid PA denials for cardiometabolic drugs succeeded at a rate of approximately 54% when clinical trial data was submitted. [11]

How to Get Farxiga Cheaper: All Cost-Reduction Pathways

AstraZeneca AZ&Me Patient Assistance Program

AZ&Me (formerly AstraZeneca Foundation Patient Assistance Program) provides Farxiga at no cost to uninsured or underinsured patients who meet income eligibility criteria. For 2025, eligibility requires household income at or below 400% of the federal poverty level (FPL) and no adequate prescription drug coverage. Applications are submitted at azandme.com or by calling 1-800-292-6363. The FDA's Orange Book lists dapagliflozin as a brand-only product with no currently approved generic as of mid-2025, which makes manufacturer assistance programs particularly important. [1]

Farxiga Co-Pay Card (Commercial Insurance Only)

AstraZeneca offers a co-pay savings card for commercially insured patients that can reduce monthly out-of-pocket cost to as low as $0 for eligible fills. Federal law (the Anti-Kickback Statute exception at 42 CFR § 1001.952(h)) prohibits applying manufacturer co-pay cards to government-funded insurance including Medicaid, Medicare Part D, CHIP, and TRICARE. Patients on Medicaid cannot use the commercial co-pay card, making AZ&Me and state pharmaceutical assistance programs their primary recourse.

State Pharmaceutical Assistance Programs (SPAPs)

Fifteen states operate SPAPs that wrap around Medicaid coverage to reduce brand drug costs. Notable programs include: New Jersey's PAAD program (income limit approximately $37,722 single / $46,458 married for 2025), Pennsylvania's PACE program, New York's EPIC program, and Massachusetts' Prescription Advantage. These programs are separate from Medicaid and can reduce the effective co-pay for non-preferred brands like Farxiga to $0, $15 for qualifying seniors.

GoodRx and Other Discount Cards

GoodRx, RxSaver, and SingleCare are third-party discount programs that negotiate cash prices with pharmacy benefit managers. GoodRx prices for dapagliflozin 10 mg (30 tablets) ranged from approximately $430 to $475 at major chain pharmacies in July 2025. Discount cards cannot be stacked with Medicaid; they function as an alternative to insurance, not a supplement. A patient who chooses to use GoodRx instead of Medicaid for a single fill is paying cash price and that fill will not count toward any deductible or out-of-pocket maximum.

Mark Cuban's Cost Plus Drugs

Cost Plus Drugs (costplusdrugs.com) listed dapagliflozin as unavailable as of mid-2025 because no FDA-approved generic exists. If a generic is approved by the FDA (the earliest plausible date is after dapagliflozin's exclusivity expiration), Cost Plus pricing could become relevant. Monitor the FDA Orange Book entry for NDA 202293 for exclusivity expiration updates. [1]

HSA and FSA Eligibility for Farxiga

Farxiga qualifies as an eligible medical expense under IRS Publication 502, which governs health savings accounts (HSA) and flexible spending accounts (FSA). Prescription drugs that require a physician's order are eligible expenses regardless of whether the drug treats a chronic condition like T2D, HFrEF, or CKD. [12]

How HSA/FSA Payments Work at the Pharmacy

Present your HSA debit card or FSA card at the pharmacy counter the same way you would a credit card. Most major pharmacy chains (CVS, Walgreens, Rite Aid, Walmart Pharmacy, Kroger Pharmacy) accept HSA/FSA cards directly. If you pay out of pocket first, retain the itemized receipt and submit for reimbursement through your HSA or FSA administrator's portal.

HSA vs. FSA: Key Difference for Farxiga Users

HSA funds roll over year to year with no expiration; FSA funds are subject to the "use it or lose it" rule (with a 2025 carryover maximum of $660 for health FSAs). For a patient filling a 90-day supply of Farxiga at cash price, planning the FSA purchase in Q4 to use remaining FSA balances is a practical strategy. The 2025 HSA contribution limit is $4,300 for self-only coverage and $8,550 for family coverage under IRS guidelines. [12]

Clinical Efficacy Summary: Why Physicians Fight for PA Approval

Dapagliflozin's clinical evidence base is among the strongest of any cardiometabolic agent approved in the past decade.

Glycemic Outcomes in T2D

The DECLARE-TIMI 58 trial (N=17,160) compared dapagliflozin 10 mg to placebo over a median 4.2 years. Dapagliflozin reduced hospitalization for heart failure by 27% (HR 0.73; 95% CI 0.61 to 0.88; P<0.001) and slowed progression of renal disease in the cardiorenal composite endpoint. [13] The FDA approved the T2D indication on January 8, 2014, based on earlier Phase 3 data showing mean A1C reduction of 0.54 to 0.89 percentage points versus placebo across baseline A1C strata. [1]

Cardiovascular and Renal Outcomes

DAPA-HF (N=4,744) enrolled patients with HFrEF (LVEF below 40%) with or without T2D. At 18.2 months median follow-up, dapagliflozin reduced the primary composite endpoint (worsening HF or CV death) with NNT of 21. [4] DAPA-CKD (N=4,304) was stopped early at a median 2.4 years due to overwhelming efficacy; the NNT to prevent one primary composite event was 19. [5]

Safety Profile Relevant to Medicaid Populations

The most clinically relevant adverse effects in Medicaid populations are genital mycotic infections (occurring in approximately 6.6% of women and 3.1% of men versus 1.4% and 0.6% on placebo in Phase 3 data) and Fournier's gangrene (a rare but serious FDA-labeled warning). [1] Diabetic ketoacidosis (DKA) risk is present primarily in off-label use in type 1 diabetes. The FDA issued a Drug Safety Communication on SGLT2 inhibitor-associated DKA in May 2015. [14]

2026 Outlook: Formulary Changes to Watch

The Inflation Reduction Act (IRA) of 2022 authorized Medicare to negotiate drug prices directly, with the first negotiated prices taking effect January 1, 2026, for a list of ten drugs. Dapagliflozin was not on the first negotiation list, but SGLT2 inhibitors as a class may appear on subsequent lists. IRA negotiations could affect commercial and Medicaid rebate dynamics because manufacturers may restructure rebate agreements across payer types in response. [15]

State Medicaid directors have indicated that if negotiated Medicare prices fall below current Medicaid AMP-based prices, they may trigger Most Favored Nation (MFN) clauses in supplemental rebate contracts. This could either increase dapagliflozin's preferred tier placement or reduce its cost-sharing tier. Prescribers managing Medicaid patients on dapagliflozin should recheck formulary status in January 2026 when IRA pricing takes effect.