Does Humana Cover Farxiga (Dapagliflozin)?

What Is Farxiga and Why Does the Indication on Your Prescription Matter?

Farxiga is the brand name for dapagliflozin, an SGLT2 inhibitor approved by the FDA for three distinct clinical indications. Each indication can affect how Humana classifies the drug on its formulary and whether prior authorization is required. The three approved uses are: type 2 diabetes mellitus (to improve glycemic control), heart failure with reduced ejection fraction (HFrEF, regardless of diabetes status), and chronic kidney disease (CKD) to slow progression.

The FDA approved dapagliflozin 10 mg for heart failure in May 2020 and for CKD in April 2021, expanding on the original 2014 type 2 diabetes approval (FDA Farxiga label). Because these are three separate regulatory pathways, your insurer may cover the drug under one indication and deny it under another.

Humana's medical-policy documents distinguish between diabetes, cardiovascular, and renal indications when assigning tier placement and prior-authorization requirements. Presenting a prescription written specifically for CKD or heart failure, with matching ICD-10 codes, can meaningfully change your coverage outcome compared to a generic "type 2 diabetes management" prescription.

The DAPA-HF trial (N=4,744) demonstrated that dapagliflozin 10 mg reduced the composite of worsening heart failure or cardiovascular death by 26% relative to placebo (hazard ratio 0.74 to 95% CI 0.65, 0.85, P<0.001) [1]. That cardiovascular mortality benefit is the clinical basis insurers increasingly use to justify coverage under heart-failure indications rather than treating the drug as a simple glucose-lowering agent.

What Formulary Tier Is Farxiga on Humana Plans?

Farxiga most commonly appears on Tier 3 or Tier 4 of Humana's commercial formularies, and on Tier 3 through Tier 5 of Humana Medicare Advantage plans. Tier placement sets your cost-sharing before any deductible is met.

On a Humana commercial plan, Tier 3 cost-sharing typically runs $45, $95 for a 30-day supply after the deductible. Tier 4 may require 25 to 40% coinsurance, which on a $620 list price translates to $155, $248 per fill. Humana's Medicare Advantage plan formularies are published annually in the plan's Evidence of Coverage document; the specific tier assignment varies by plan name (for example, Humana Gold Plus vs. Humana Choice vs. HumanaChoice PPO) and by county.

To find your exact tier, go to Humana's drug-cost lookup tool or call the pharmacy benefit number on the back of your ID card. Always search for "dapagliflozin" as well as "Farxiga," because some plan formularies list the brand name only, some list the generic, and some list both at different tiers.

The American Diabetes Association's 2024 Standards of Care place SGLT2 inhibitors as preferred agents for patients with type 2 diabetes who also have established cardiovascular disease, heart failure, or CKD, regardless of baseline HbA1c (ADA Standards of Care 2024) [2]. Documenting that your patient meets one of these high-priority clinical categories strengthens a formulary-exception request if the drug is not on formulary at all.

HealthRX Tier-Action Framework: If Farxiga is on Tier 4 or higher, request a formulary exception before filling. The exception process is faster than an appeal and, if successful, drops cost-sharing to a lower tier immediately.

Does Humana Require Prior Authorization for Farxiga?

Yes. Prior authorization (PA) is required on the majority of Humana commercial and Medicare Advantage plans that do include Farxiga on formulary. The degree of difficulty ranges from moderate for commercial plans to frequently denied on some Medicare Advantage plans, particularly when the prescription is written for a secondary indication like CKD without full supporting documentation.

Typical prior-authorization criteria Humana applies include:

For type 2 diabetes: The patient must have a confirmed diagnosis of T2DM. Many plans additionally require a documented HbA1c at or above a threshold (commonly 7.5% or 8.0%), or evidence that the prescribing physician has considered metformin first. Some plans require documentation of a contraindication or intolerance to metformin rather than explicit step therapy.

For heart failure (HFrEF): PA forms typically require documentation of a left ventricular ejection fraction (LVEF) of 40% or below, confirmed by echocardiogram or imaging report date within the last 12 months, plus the patient's current NYHA functional class. The prescribing cardiologist or internist should attach the echo report.

For CKD: Humana PA forms for the CKD indication generally ask for the most recent eGFR value (the CKD approval covers patients with eGFR of 25 to 75 mL/min/1.73 m²), urine albumin-to-creatinine ratio (UACR) if available, and confirmation of the underlying cause of CKD. The DAPA-CKD trial (N=4,304) showed a 39% reduction in the composite of sustained eGFR decline of 50% or more, end-stage kidney disease, or renal or cardiovascular death (HR 0.61 to 95% CI 0.51, 0.73, P<0.001) [3]. Including that clinical context in the PA letter can help demonstrate medical necessity.

The PA request should be submitted by the prescribing physician's office directly through Humana's provider portal or by fax. Turnaround for standard PA is up to 72 hours for commercial plans and up to 72 hours for Medicare Advantage non-urgent cases. Urgent requests (when a standard timeline could seriously jeopardize health) must be answered within 24 hours under Medicare Advantage rules.

Does Humana Require Step Therapy Before Farxiga?

Step therapy is common on Humana Medicare Advantage plans and less consistent on commercial plans. Step therapy means Humana requires the patient to try and fail (or show a contraindication to) one or more preferred agents before it will approve Farxiga.

For the type 2 diabetes indication, Humana's step-therapy protocols frequently require a documented trial of metformin, a sulfonylurea (such as glipizide or glimepiride), or an older SGLT2 inhibitor that appears on a lower formulary tier. Canagliflozin (Invokana) or empagliflozin (Jardiance) may be listed as preferred alternatives on some Humana formularies because AstraZeneca's rebate contracts differ by plan year.

For heart failure and CKD indications, step therapy is generally not applied because no equivalent generic or lower-tier SGLT2 inhibitor has the exact same FDA labeling for those indications. If a Humana PA denial cites step therapy for a heart failure or CKD prescription, that denial may be medically inappropriate and is worth challenging immediately.

Step-therapy protections under federal and state law vary. The Centers for Medicare and Medicaid Services (CMS) requires Medicare Advantage plans to allow step-therapy exceptions when a clinician certifies that the required step drug is contraindicated, is clinically ineffective, or would cause adverse effects (CMS Medicare Advantage Step Therapy Policy) [4]. Document any prior adverse reaction or treatment failure in writing before submitting the PA.

How to Appeal a Humana Denial of Farxiga

A denial is not the end of the road. Four escalating pathways exist, each with specific deadlines.

Level 1: Internal Humana Redetermination. File within 60 days of the denial notice for Medicare Advantage, or within 30 to 180 days depending on your commercial plan's Summary Plan Description. Submit a physician-authored letter of medical necessity that directly addresses every criterion in the denial reason. Attach clinical notes, lab values (HbA1c, eGFR, LVEF), and relevant trial citations. The DAPA-HF and DAPA-CKD data are particularly persuasive because they document mortality and hospitalization reductions, not just surrogate endpoints. Humana must respond within 72 hours (urgent) or 7 calendar days (standard) for Medicare Advantage redeterminations.

Level 2: Independent Review Organization (Medicare Advantage). If Humana upholds the denial, the case moves to MAXIMUS Federal Services, the CMS-contracted IRO. You do not need to do anything to trigger this escalation; Humana is required to auto-forward the case if the dollar threshold is met. MAXIMUS issues a decision within 72 hours (expedited) or 7 days (standard).

Level 3: Office of Medicare Hearings and Appeals (OMHA). If the MAXIMUS decision is unfavorable, you may request a hearing before an Administrative Law Judge (ALJ) within 60 days. The amount in controversy must reach $180 (2024 threshold) for a case to qualify. Most Farxiga denials exceed that threshold within a single month.

Level 4: Medicare Appeals Council and Federal District Court. These levels exist but are rarely needed for a single prescription benefit dispute.

For commercial (non-Medicare) Humana plans, the equivalent pathway runs through Humana's internal appeal, then an external Independent Review Organization designated under the plan's state law, and finally potential legal action or state insurance commissioner complaint.

The Endocrine Society's clinical practice guidelines state: "SGLT2 inhibitors are recommended for patients with T2D and established cardiovascular disease, CKD (eGFR 20 to 45 mL/min/1.73 m² or UACR >200 mg/g), or heart failure to reduce cardiovascular and renal risk, independent of glucose control" (Endocrine Society 2023 Diabetes Guidelines) [5]. Quoting this guideline recommendation verbatim in the appeal letter establishes that denial of Farxiga contradicts expert medical consensus.

Does Humana Cover Farxiga for Weight Loss?

No. Humana does not cover Farxiga for weight loss, and neither does any other major insurer. Dapagliflozin is not FDA-approved for weight management. The FDA-approved weight-loss indications requiring SGLT2 inhibitors do not exist in current regulatory labeling.

CMS policy explicitly prohibits Medicare Advantage plans from covering weight-loss medications unless the drug has a separate FDA approval for obesity or weight management. Dapagliflozin produces modest body weight reductions (typically 2 to 3 kg over 24 weeks in clinical trials) as a secondary effect of glucosuria, but that effect does not constitute an approved weight-loss indication [6].

If weight loss is a primary clinical goal, the appropriate conversation is about GLP-1 receptor agonists with FDA weight-management approvals, such as semaglutide 2.4 mg (Wegovy) or liraglutide 3 mg (Saxenda). Prescribing Farxiga with a primary ICD-10 code for obesity (E66.x) will be denied by Humana and is not supported by the FDA label.

Can You Use the AstraZeneca Savings Card with Humana?

The AstraZeneca Farxiga savings card reduces out-of-pocket cost to as low as $10 per month for eligible commercially insured patients. The critical restriction: the savings card cannot be used with any federal health-care program, including Medicare Advantage, Medicaid, or any Humana plan that qualifies as a federal program.

For patients on Humana commercial plans (employer-sponsored or individual-market), the savings card is generally usable as long as the plan does not classify it as a health reimbursement account (HRA) or health savings account (HSA)-eligible high-deductible plan where manufacturer coupons are prohibited by IRS rules.

Eligibility and enrollment for the AstraZeneca savings card can be verified at the manufacturer's patient-support site. Income-based free-drug programs through AstraZeneca's AZ&Me Prescription Savings program may cover patients who are uninsured or underinsured, including those on Medicare with limited income who do not qualify for Low Income Subsidy (LIS/Extra Help).

Patients on Humana Medicare Advantage who are denied Farxiga and cannot afford the cash price of approximately $620 per month should ask their physician to explore whether empagliflozin or canagliflozin, which have similar (though not identical) CKD and heart failure trial data, are covered at a lower tier on their specific plan.

What Supporting Clinical Evidence Should Be in a Prior-Authorization or Appeal Submission?

Strong PA and appeal submissions include clinical trial data tied directly to the patient's diagnosis. Below are the most relevant data points by indication.

Heart failure (HFrEF): The DAPA-HF trial (N=4,744, published in NEJM 2019) showed dapagliflozin 10 mg reduced the primary composite endpoint (worsening heart failure or cardiovascular death) by 26% over a median 18.2 months (HR 0.74, P<0.001) [1]. The benefit was consistent regardless of whether patients had diabetes. A 2022 pooled analysis of DAPA-HF and EMPEROR-Reduced confirmed the SGLT2 inhibitor class effect in HFrEF [7].

CKD: The DAPA-CKD trial (N=4,304, NEJM 2020) showed a 39% relative risk reduction in the primary composite of sustained eGFR decline of 50% or more, ESKD, or renal or cardiovascular death (HR 0.61, P<0.001) [3]. The trial enrolled patients with and without type 2 diabetes, supporting the CKD indication independently of glycemic status.

Type 2 diabetes and cardiovascular disease: The DECLARE-TIMI 58 trial (N=17,160, NEJM 2019) showed dapagliflozin reduced the rate of hospitalization for heart failure or cardiovascular death (HR 0.83 to 95% CI 0.73, 0.95, P=0.005) in a broad T2DM population, the largest cardiovascular outcomes trial for any SGLT2 inhibitor at the time of publication [8].

Attaching the relevant abstract or citing the PMID number in a PA letter signals to the reviewing pharmacist or physician that the request is evidence-based rather than preference-based.

Practical Checklist Before Submitting a Humana PA for Farxiga

A complete submission avoids the most common reasons for denial. Work through this list before the prescriber's office submits the request.

1. Confirm the ICD-10 code matches the FDA-approved indication being requested (E11.x for T2DM, I50.x for heart failure, N18.x for CKD).
2. Attach the most recent HbA1c (for diabetes), echocardiogram report with LVEF (for heart failure), or eGFR and UACR lab results (for CKD), dated within 12 months.
3. Document any prior SGLT2 inhibitor trials, adverse effects, or contraindications if step therapy applies.
4. Include the prescriber's direct phone and fax number so the Humana clinical reviewer can call for clarification without restarting the clock.
5. Request expedited review if the patient is currently hospitalized or being discharged with a new heart failure or CKD diagnosis, since standard 72-hour timelines apply to non-urgent cases.

The FDA label for Farxiga specifies that the drug is contraindicated in patients with eGFR persistently below 25 mL/min/1.73 m² for the CKD indication, and that it should not be initiated in patients on dialysis (FDA Farxiga Prescribing Information) [9]. Confirming the patient's eGFR is above 25 before submitting the PA eliminates one common pharmacist-level rejection.