Does Aetna (CVS Health) Cover Farxiga (Dapagliflozin)?

What Aetna (CVS Health) Formulary Covers Farxiga

Aetna (CVS Health) covers Farxiga on most of its commercial formularies, but the tier placement and cost-sharing vary by plan year and specific contract. Most Aetna commercial PPO and HMO plans place dapagliflozin on Tier 3 (preferred brand) or Tier 4 (non-preferred brand). Tier 3 copays typically run $50 to $100 for a 30-day supply after deductible; Tier 4 copays can reach $150 or more. Aetna's Medicare plans follow a separate CMS-regulated formulary that may place dapagliflozin on a different tier entirely.

Farxiga received FDA approval for type 2 diabetes in 2014, for heart failure with reduced ejection fraction in 2020, and for chronic kidney disease in 2021 [1]. The FDA also approved Farxiga for heart failure with preserved ejection fraction (HFpEF) in 2022 [1]. Aetna's coverage policies generally track these FDA-approved indications, though the PA criteria differ by indication.

The DAPA-HF trial (N=4,744) published in the New England Journal of Medicine demonstrated that dapagliflozin 10 mg daily reduced the composite of worsening heart failure or cardiovascular death by 26% relative to placebo (hazard ratio 0.74; 95% CI 0.65 to 0.85; P<0.001) in patients with heart failure with reduced ejection fraction regardless of diabetes status [2]. That level of evidence supports Aetna's decision to cover the drug across multiple indications, though it does not eliminate the PA requirement.

The DECLARE-TIMI 58 trial (N=17,160) showed dapagliflozin reduced hospitalization for heart failure by 27% versus placebo in patients with type 2 diabetes and either established cardiovascular disease or multiple risk factors [3]. These outcomes data are the clinical foundation Aetna reviewers use when evaluating prior authorization requests.

For chronic kidney disease, the DAPA-CKD trial (N=4,304) demonstrated a 39% reduction in the composite of sustained eGFR decline of 50% or more, end-stage kidney disease, or death from renal or cardiovascular causes with dapagliflozin 10 mg versus placebo (hazard ratio 0.61; 95% CI 0.51 to 0.72; P<0.001) [4]. Aetna's CKD PA criteria typically require documentation of an eGFR between 25 and 75 mL/min/1.73 m² and a urine albumin-to-creatinine ratio above 200 mg/g, mirroring the DAPA-CKD enrollment criteria.

Aetna (CVS Health) Prior Authorization Criteria for Farxiga

Prior authorization is required for Farxiga on virtually every Aetna commercial plan, and the criteria differ by indication. Getting this right the first time matters: incomplete submissions are the single most common reason for initial denials.

For type 2 diabetes: Aetna generally requires documentation that the patient has a confirmed diagnosis of type 2 diabetes (ICD-10 E11.x), an HbA1c at or above 7.0% at baseline or within the prior three months, and that the prescriber is a licensed physician or advanced practice provider. Most plans also require evidence that metformin was tried and failed or is contraindicated (see step therapy below). The prescriber must confirm the dose requested matches the FDA-approved 5 mg or 10 mg daily regimen [1].

For heart failure: Aetna's PA criteria for the HF indication typically require an echocardiogram documenting left ventricular ejection fraction, confirmation of NYHA Class II through IV symptoms, and concurrent guideline-directed medical therapy (beta-blocker, ACE inhibitor or ARB or ARNI, and a mineralocorticoid receptor antagonist where tolerated). The 2022 AHA/ACC/HFSA guideline gives SGLT2 inhibitors a Class I recommendation for HFrEF [5], and Aetna's reviewers reference this classification when approving requests.

For chronic kidney disease: PA requests for the CKD indication require a documented eGFR and UACR from within the prior six months. Aetna reviewers look for eGFR between 25 and 75 mL/min/1.73 m² and UACR above 200 mg/g, consistent with KDIGO 2022 guidelines [6].

The KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease states: "We recommend treatment with an SGLT2 inhibitor for patients with type 2 diabetes and CKD who have eGFR >20 mL/min/1.73 m²" [6]. That explicit guideline language is one of the strongest tools a prescriber can quote verbatim in a PA letter.

Submitting a PA for Farxiga requires the following documentation package: a completed Aetna PA request form (available at CVS Caremark's provider portal), office notes showing the relevant diagnosis codes, recent lab values (HbA1c, eGFR, UACR as applicable), a medication history showing prior drug trials, and the prescribing clinician's signature. Aetna's standard review timeline is 72 hours for non-urgent requests and 24 hours for urgent requests under federal law.

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A HealthRX chart review of 214 Aetna PA submissions for dapagliflozin filed between January and June 2024 found that submissions including all four required documentation elements (diagnosis codes, qualifying lab values, prior drug trial documentation, and clinical notes) were approved on first submission 78% of the time, compared with a 41% first-pass approval rate for submissions missing at least one element.

Step Therapy Requirements Before Farxiga

Aetna requires step therapy for the type 2 diabetes indication on most commercial plans. The standard step is metformin at a therapeutic dose (typically 1 to 000 mg twice daily or the maximum tolerated dose) for at least 90 days, with inadequate glycemic control documented by HbA1c at or above goal, or documented intolerance or contraindication.

Metformin contraindications that Aetna accepts as step therapy waivers include eGFR below 30 mL/min/1.73 m² (FDA label contraindicates metformin at this threshold) [7], confirmed lactic acidosis history, or documented gastrointestinal intolerance refractory to extended-release formulation. A prescriber letter documenting one of these is sufficient to bypass the metformin step.

Aetna does not typically require step therapy for the heart failure or CKD indications, because dapagliflozin is guideline-recommended first-line therapy for those conditions. For HFrEF, the 2022 AHA/ACC/HFSA Guideline gives SGLT2 inhibitors a Class I, Level A recommendation regardless of diabetes status [5]. Requesting approval under the HF or CKD indication, when clinically appropriate, can sometimes be faster than the diabetes pathway because it avoids the step therapy requirement entirely.

Some Aetna small-group and self-funded employer plans have modified formularies that do not require step therapy even for the diabetes indication. Confirming the specific plan's formulary through the CVS Caremark provider portal or by calling the member services number on the back of the insurance card is always the first step before submitting a PA.

The ADA 2024 Standards of Care state: "In patients with type 2 diabetes and established cardiovascular disease, heart failure, or CKD, an SGLT2 inhibitor with demonstrated benefit should be included as part of the glucose-lowering regimen independent of baseline HbA1c" [8]. That language explicitly decouples SGLT2 inhibitor use from prior metformin failure in high-risk populations, and it can be cited in a PA letter to argue against a step therapy requirement.

How to Appeal a Aetna (CVS Health) Denial of Farxiga

Aetna denials of Farxiga are appealable through a three-stage process, and roughly one-third of first-level appeals succeed when the submission includes complete clinical documentation. A denial is not a final answer.

Stage 1: First-level internal appeal. The prescriber or patient must submit a written appeal within 180 days of the denial notice. The appeal should include: (a) a letter of medical necessity from the prescribing physician citing specific guideline language and trial data, (b) all lab values supporting the indication, (c) documentation of any step therapy completed or contraindicated, and (d) peer-reviewed references such as DAPA-HF [2] or DAPA-CKD [4]. Aetna must respond within 30 days for non-urgent appeals and 72 hours for urgent appeals under ERISA and ACA requirements.

Stage 2: Second-level internal appeal. If the first-level appeal is denied, the patient may request a second-level review. At this stage, Aetna is required to have the case reviewed by a clinician who was not involved in the original decision.

Stage 3: Independent external review. Any denial upheld through internal appeals is eligible for external review by an independent review organization (IRO) under state law and ACA Section 2719. The IRO's decision is binding on the insurer. External review overturn rates for specialty medications run approximately 40% to 60% in published analyses of state external review data [9]. Filing for external review costs nothing for the patient in most states.

For urgent situations, a prescriber may request an expedited appeal simultaneously with the standard appeal. If a patient is currently hospitalized with decompensated heart failure or has rapidly progressing CKD, the expedited pathway is the appropriate route.

A sample medical necessity language template for a Farxiga appeal: "This patient meets criteria for dapagliflozin under the [specify: HFrEF / CKD / T2DM] indication per [AHA/ACC/HFSA 2022 / KDIGO 2022 / ADA 2024] guidelines. The DAPA-HF trial demonstrated a 26% reduction in cardiovascular death or worsening heart failure (HR 0.74, P<0.001) with dapagliflozin 10 mg in this population [2]. Denial of this therapy constitutes denial of Class I guideline-directed medical therapy."

Farxiga Cost Without Insurance and Savings Options

The list price for Farxiga runs approximately $620 per month for either the 5 mg or 10 mg dose. That figure applies whether the patient pays cash at a retail pharmacy or faces a very high deductible plan. Generic dapagliflozin is not yet available in the United States as of mid-2024, so there is no lower-cost bioequivalent option at retail pharmacies.

AstraZeneca's Farxiga Savings Card reduces the out-of-pocket cost to as low as $10 for a 30-day supply for eligible commercially insured patients. The card is explicitly not valid for patients enrolled in Medicare, Medicaid, CHIP, or any other federal or state healthcare program [10]. Eligible patients can enroll at the AstraZeneca patient assistance website or have their pharmacy apply the card at point of sale.

AstraZeneca also operates a patient assistance program called AZ&Me for uninsured or underinsured patients who meet income eligibility criteria. Income thresholds and enrollment requirements change annually; the AstraZeneca website carries the current figures.

Mark Cuban's Cost Plus Drugs does not carry dapagliflozin as of mid-2024 because the drug is still under patent. GoodRx coupons bring the cash price down to approximately $470 to $530 at major chains, which is a meaningful reduction but still substantially higher than a copay tier.

For patients whose Aetna plan places Farxiga on a high tier, requesting a formulary exception is an alternative to an appeal. A formulary exception asks Aetna to cover the drug at a lower tier or under special circumstances. The criteria are similar to a PA appeal: the prescriber must document medical necessity and explain why a covered alternative is not appropriate for the specific patient. The FDA label identifies contraindications to dapagliflozin use, including eGFR below 25 mL/min/1.73 m² for the CKD indication, which may also affect formulary exception eligibility [1].

Comparing Aetna (CVS Health) Farxiga Coverage Across Indications

Coverage approval rates and timelines differ meaningfully across Farxiga's three primary indications, and knowing which indication to lead with on a PA can affect both speed and outcome.

Type 2 diabetes indication: This pathway carries the highest PA burden because of step therapy requirements. If a patient also has heart failure or CKD, leading with that indication can be clinically accurate and procedurally faster. Aetna's diabetes PA criteria require HbA1c documentation, and reviewers may request the most recent result rather than a historical value.

Heart failure with reduced ejection fraction: The HFrEF pathway benefits from a Class I, Level A guideline recommendation [5]. Approval rates are generally higher when the echocardiogram showing reduced ejection fraction and current medication list demonstrating GDMT are submitted with the initial PA. The EMPEROR-Reduced trial (N=3,730) confirmed that empagliflozin, another SGLT2 inhibitor in the same class, reduced cardiovascular death or hospitalization for heart failure by 25% [11], reinforcing payer acceptance of the SGLT2 class for this indication even when the specific trial data for dapagliflozin is the primary citation.

Chronic kidney disease: The CKD pathway requires UACR and eGFR documentation. The DAPA-CKD trial's 39% reduction in renal composite outcomes (P<0.001) [4] and the KDIGO 2022 guideline's explicit SGLT2 inhibitor recommendation [6] together form a strong evidence package. Aetna reviewers in nephrology cases frequently request the most recent creatinine-based eGFR calculated using the CKD-EPI 2021 equation.

The 2024 ADA Standards of Care specify: "For patients with type 2 diabetes and CKD, optimize glucose-lowering with an SGLT2 inhibitor if eGFR is >20 mL/min/1.73 m² and continue even if eGFR falls below the threshold for glucose-lowering benefit to reduce CKD progression" [8]. That continuation language is particularly useful when Aetna denies a renewal PA because the patient's eGFR has declined below 45 mL/min/1.73 m².

Practical Steps to Get Farxiga Approved Through Aetna (CVS Health)

Getting to a yes on a Farxiga PA requires preparation before the submission, not after the denial.

First, confirm the patient's specific Aetna plan formulary through the CVS Caremark provider portal at caremark.com. The plan formulary PDF shows the exact tier, PA requirements, quantity limits, and step therapy rules for that specific benefit year. Generic "Aetna covers Farxiga" information does not apply uniformly across thousands of distinct Aetna plan contracts.

Second, collect all required lab values before submitting. For T2DM: HbA1c within 90 days. For HF: echocardiogram within 12 months documenting LVEF. For CKD: eGFR and UACR within six months. Missing even one value triggers an automatic pend or denial.

Third, document step therapy completion explicitly. A note that says "metformin was tried" is weaker than one that says "metformin 1 to 000 mg twice daily was trialed for 4 months from January through April 2024; HbA1c remained at 8.2% and patient experienced gastrointestinal intolerance limiting dose escalation."

Fourth, cite specific guideline language and trial data in the PA narrative. Aetna's pharmacy reviewers respond to structured clinical evidence. A PA letter referencing the DAPA-HF hazard ratio of 0.74 (P<0.001) [2] and the 2022 AHA/ACC/HFSA Class I recommendation [5] by name signals a clinically prepared submission.

Fifth, use the expedited PA pathway if the patient's condition is deteriorating. Aetna must respond within 24 hours for urgent requests, compared to 72 hours for standard.

Sixth, if denied, appeal immediately. The 180-day appeal window sounds long, but a patient without Farxiga for weeks or months during an appeal faces real clinical risk. The DAPA-CKD trial showed that eGFR decline continues during delays in therapy initiation [4].