Does Anthem (Elevance Health) Cover Farxiga (Dapagliflozin)?

How Anthem (Elevance Health) Classifies Farxiga on Its Formulary

Anthem places Farxiga on Tier 3 (preferred brand) or Tier 4 (non-preferred brand) depending on the specific plan product. Most commercial PPO and HMO formularies list dapagliflozin as a preferred brand when a PA is satisfied, meaning cost-sharing sits in the $50, $120 per-fill range after deductible. Certain employer-sponsored plans with a narrow formulary push it to Tier 4, where copays can reach $150, $200 per 30-day supply.

Farxiga received its first FDA approval for type 2 diabetes in January 2014, expanded to heart failure with reduced ejection fraction (HFrEF) in May 2020, and gained a chronic kidney disease (CKD) indication in April 2021 [1]. Anthem's medical policy has been updated after each approval, so the indication you list on the PA form determines which step-therapy pathway applies.

The FDA label covers dapagliflozin 10 mg once daily for HFrEF and CKD, and either 5 mg or 10 mg for type 2 diabetes [1]. Submitting the wrong dose for the wrong indication is one of the most common reasons a PA is initially rejected, according to pharmacy benefit data reviewed by the HealthRX clinical team.

Anthem's National Preferred Formulary, which governs the majority of its self-funded and fully insured commercial accounts, is updated quarterly. If your plan renewed after January 1, 2025, verify the current tier status through Anthem's online formulary lookup or by calling the pharmacy benefits number on your member card before assuming Tier 3 applies.

Prior Authorization Criteria Anthem Uses for Farxiga

Anthem requires a PA for every FDA-approved indication of Farxiga. The clinical criteria differ by indication, but all three pathways share a common documentation checklist.

For type 2 diabetes, Anthem's PA criteria generally require:

• A confirmed diagnosis of type 2 diabetes (ICD-10: E11.x) with documentation of HbA1c.
• A trial of metformin at an adequate dose (typically 1 to 000 mg twice daily for at least 90 days) unless the patient has a documented contraindication such as an eGFR <30 mL/min/1.73 m² or a history of metformin-associated lactic acidosis [2].
• If a second agent is required, some Anthem plans also want documentation that a generic sulfonylurea or generic DPP-4 inhibitor was tried, though this second step is plan-specific.

For heart failure with reduced ejection fraction, the criteria align with the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure, which gives SGLT2 inhibitors a Class I, Level of Evidence A recommendation for patients with HFrEF [3]. Anthem typically asks for:

• LVEF <40% confirmed by echocardiogram, cardiac MRI, or nuclear imaging within the past 12 months.
• Stable background therapy with an ACE inhibitor, ARB, or ARNI plus a beta-blocker for at least 30 days, unless contraindicated [3].
• New York Heart Association functional class II, III, or IV.

For CKD, the PA criteria reflect the evidence from the DAPA-CKD trial (N=4,304), which showed dapagliflozin 10 mg reduced the composite of sustained eGFR decline of 50% or more, end-stage kidney disease, or renal or CV death by 39% vs. placebo (hazard ratio 0.61 to 95% CI 0.51, 0.72, P<0.001) [4]. Anthem commonly requires:

• eGFR 25 to 75 mL/min/1.73 m² at baseline [4].
• Urine albumin-to-creatinine ratio (UACR) greater than 200 mg/g [4].
• Stable renin-angiotensin-aldosterone system (RAAS) blockade with an ACE inhibitor or ARB for at least 4 weeks unless contraindicated [4].

The prescribing clinician must submit lab values (HbA1c, eGFR, UACR, or echocardiogram report) with the PA request. Missing even one lab value is enough for an automatic denial that then requires peer-to-peer review to reverse.

Step Therapy Requirements Before Farxiga Is Approved

Step therapy is mandatory on most Anthem commercial plans for the type 2 diabetes indication. The standard sequence requires metformin first, as noted above. Some plans add a second generic agent before Farxiga is unlocked. Anthem's step therapy policies for the HFrEF and CKD indications are less aggressive because no lower-cost generic SGLT2 inhibitor has received FDA approval for those indications at the time of this writing.

The American Diabetes Association's 2024 Standards of Care position SGLT2 inhibitors as preferred add-on agents in patients with established cardiovascular disease, CKD, or heart failure, independent of HbA1c [5]. Citing this guideline directly in the PA request, rather than framing the request purely around glycemic control, can shorten the step-therapy requirement for patients who qualify on the basis of CV or renal risk.

For patients with HFrEF, the DAPA-HF trial (N=4,744) reported that dapagliflozin 10 mg reduced the composite of worsening heart failure or cardiovascular death by 26% vs. placebo (HR 0.74 to 95% CI 0.65, 0.85, P<0.001) [6]. The benefit was consistent regardless of whether patients had diabetes. Citing this trial result in the PA letter, alongside the Class I AHA/ACC/HFSA guideline recommendation [3], gives Anthem's pharmacy reviewers the clinical evidence they need to bypass step therapy for HFrEF patients.

How to Submit a Farxiga PA Request to Anthem

Anthem accepts PA requests through three channels: the Availity provider portal, a fax-based PA form, and a phone request to the pharmacy benefit management line. The Availity portal is the fastest route; electronic submissions typically receive a decision within 14 to 24 hours for standard requests and within 8 hours for urgent or expedited requests.

The PA packet should include:

1. Completed Anthem PA request form specifying the indication (diabetes, HFrEF, or CKD).
2. Office notes confirming the diagnosis with ICD-10 code.
3. Relevant labs: HbA1c dated within 6 months (diabetes), echo report (HFrEF), or eGFR and UACR (CKD).
4. Documentation of step therapy trials or a written statement explaining why step therapy is contraindicated.
5. The prescribing clinician's NPI and DEA number.

If a PA is denied on the first pass, the denial letter must state the specific clinical criteria that were not met, per state external-review laws applicable to Anthem's service territories. That denial letter is the roadmap for the appeal.

Appealing an Anthem Denial of Farxiga

Anthem offers a two-level internal appeal before a case proceeds to an Independent Review Organization (IRO). The process below reflects Anthem's standard commercial appeal pathway.

Level 1 internal appeal must be filed within 180 days of the denial notice on most commercial plans. The appeal letter should directly address the denial reason, cite primary literature (DAPA-HF [6], DAPA-CKD [4], or the ADA 2024 Standards of Care [5]), and attach any updated lab values.

Peer-to-peer review is separate from the formal appeal. A prescribing physician can call Anthem's clinical reviewer, usually within 5 business days of a denial, to discuss the case in real time. Peer-to-peer calls resolve a meaningful share of denials before the formal appeal needs to be filed. The HealthRX clinical team recommends scheduling the peer-to-peer call as soon as the denial arrives, rather than waiting for the appeal deadline.

Level 2 internal appeal, if Level 1 fails, goes to a senior clinical committee. Turnaround is typically 30 calendar days for standard commercial appeals and 72 hours for urgent appeals.

State IRO review is the external step. Anthem members in every U.S. state have the right to request an IRO review after exhausting internal appeals, under state external-review laws and, for self-funded ERISA plans, under the Affordable Care Act's external-review provisions [7]. The IRO's decision is binding on Anthem for fully insured plans. For self-funded ERISA plans, consult the plan's Summary Plan Description, as binding status can vary.

The 2022 AHA/ACC/HFSA guideline states: "For patients with HFrEF, SGLT2 inhibitors are recommended to reduce HF hospitalizations and cardiovascular mortality" (Class I, LOE A) [3]. Placing that exact quotation in the appeal letter, with the guideline DOI, is one of the most effective arguments against an Anthem denial for the HFrEF indication.

Cost if Anthem Denies or Doesn't Cover Farxiga

The retail list price of Farxiga runs approximately $620 per month for a 30-day supply of 10 mg tablets. Patients who pay out of pocket should check the following cost-reduction options.

AstraZeneca Savings Card. Commercially insured patients who meet eligibility requirements may pay as little as $0 to $10 per month through AstraZeneca's Farxiga Savings Card program. Medicare and Medicaid beneficiaries are excluded by federal law. Eligibility criteria and card terms are available directly from AstraZeneca.

GoodRx and pharmacy discount programs. GoodRx prices for generic dapagliflozin, when available, or for Farxiga brand may be lower than list price at certain pharmacy chains. Prices vary by zip code and negotiated network.

Medicare Part D. Farxiga's tier placement varies by Part D plan. The Inflation Reduction Act's $2,000 out-of-pocket cap took effect January 1, 2025, which limits annual cost exposure for Medicare beneficiaries regardless of tier [8].

Patient Assistance Program. AstraZeneca's AZ&Me program provides free Farxiga to uninsured or underinsured patients who meet income criteria. Applications are available at the AstraZeneca patient assistance portal.

The Clinical Evidence Supporting Farxiga Coverage

Anthem's coverage policies are evidence-driven, and understanding the trial data strengthens every PA and appeal submission.

DAPA-HF (2019, N=4,744): Dapagliflozin 10 mg once daily vs. placebo in patients with HFrEF (LVEF <40%). The primary composite endpoint (worsening HF or CV death) occurred in 16.3% of the dapagliflozin group vs. 21.2% of the placebo group (HR 0.74 to 95% CI 0.65, 0.85, P<0.001) [6]. The NNT to prevent one primary event over the 18-month median follow-up was approximately 21.

DAPA-CKD (2020, N=4,304): Dapagliflozin 10 mg vs. placebo in patients with eGFR 25 to 75 mL/min/1.73 m² and UACR 200, 5 to 000 mg/g. The primary composite (50% or greater sustained eGFR decline, ESRD, or renal/CV death) was reduced by 39% (HR 0.61, P<0.001) [4]. The trial was stopped early by the independent data monitoring committee because of overwhelming efficacy. 32% of enrolled patients did not have type 2 diabetes, confirming the kidney-protective benefit is independent of glycemic effects [4].

DECLARE-TIMI 58 (2019, N=17,160): Dapagliflozin vs. placebo in patients with type 2 diabetes and either established CV disease or multiple CV risk factors. The trial met its primary safety endpoint and showed a significant 27% reduction in the HF hospitalization rate (HR 0.73 to 95% CI 0.61, 0.88) [9]. This trial is directly relevant when arguing for Farxiga coverage in a T2D patient who also has cardiovascular risk factors.

Kidney Disease: Improving Global Outcomes (KDIGO) 2022 Clinical Practice Guideline for Diabetes Management in CKD recommends dapagliflozin or another SGLT2 inhibitor for patients with type 2 diabetes and CKD when eGFR is 20 mL/min/1.73 m² or higher [10]. Citing KDIGO 2022 in a CKD-indication PA supports coverage even when eGFR has fallen below Anthem's typical 25 mL/min/1.73 m² threshold, because current guideline language extends initiation to eGFR >20.

Farxiga for Weight Loss: Does Anthem Cover It?

Weight loss is not an FDA-approved indication for Farxiga, and Anthem does not cover dapagliflozin for that purpose. Dapagliflozin produces a modest mean weight reduction of approximately 2 to 3 kg in clinical trials, largely through glycosuria and modest caloric loss [11]. That effect is incidental, not the primary mechanism of benefit, and is not a covered use under any Anthem commercial medical policy reviewed by the HealthRX team.

Patients seeking pharmacotherapy for obesity management should discuss GLP-1 receptor agonists (semaglutide 2.4 mg, brand name Wegovy; FDA-approved for chronic weight management) with their clinician. The STEP-1 trial (N=1,961) showed semaglutide 2.4 mg produced 14.9% mean body weight loss at 68 weeks vs. 2.4% with placebo [12]. Anthem coverage criteria for Wegovy differ from those for Farxiga and require a separate PA.

What Anthem Members Should Do Right Now

If your prescriber has already determined that Farxiga is the right drug for your condition, the fastest path to coverage follows this sequence:

1. Ask your prescriber to verify your plan's current formulary tier for dapagliflozin and confirm which PA form applies to your indication (diabetes, HFrEF, or CKD).
2. Gather all required lab documentation before the PA is submitted. Missing labs are the leading cause of first-pass denial.
3. If denied, request a peer-to-peer review within 5 business days. Do not wait for the formal appeal deadline.
4. If the peer-to-peer call fails, file the Level 1 internal appeal with a formal letter citing DAPA-HF [6] or DAPA-CKD [4] and the applicable guideline (AHA/ACC/HFSA Class I [3] or ADA 2024 [5]).
5. Apply for the AstraZeneca Savings Card immediately to limit out-of-pocket cost while the appeal is pending.