Does UnitedHealthcare Cover Farxiga (Dapagliflozin)?

What Formulary Tier Is Farxiga on UnitedHealthcare?

On the majority of UnitedHealthcare commercial PPO and HMO plans, Farxiga sits at Tier 3 (non-preferred brand). That tier classification means your out-of-pocket cost after meeting the deductible is typically 40 to 50% coinsurance or a fixed copay in the $60, $100 range per 30-day supply, depending on your specific benefit design. Some employer-sponsored plans have negotiated a Tier 2 placement, so checking your Summary of Benefits and Coverage document or the UHC online formulary tool at uhc.com is the fastest way to confirm your tier.

Generic dapagliflozin became available in the United States in early 2025 after the expiration of AstraZeneca's core patents. If your plan has added a generic to Tier 1 or Tier 2, you may pay considerably less. Ask your pharmacist or benefits coordinator whether a generic dapagliflozin appears on your plan's current formulary.

The FDA first approved Farxiga for type 2 diabetes in January 2014, added heart failure with reduced ejection fraction (HFrEF) in May 2020, expanded that to heart failure with preserved ejection fraction (HFpEF) in August 2022, and approved the chronic kidney disease (CKD) indication in April 2021 [1][2]. Each indication can carry a separate clinical criterion in UHC's coverage policy, so the indication your prescriber documents directly affects which PA criteria apply.

Does UnitedHealthcare Require Prior Authorization for Farxiga?

Yes. UnitedHealthcare requires prior authorization for Farxiga across all its major commercial plan lines. The PA process is rated "moderate difficulty" relative to other brand-name SGLT2 inhibitors, meaning approval rates are reasonable when documentation is complete, but a missing lab value or an incomplete prescriber attestation will trigger an automatic denial. [3]

For the type 2 diabetes indication, UHC's published clinical coverage policies generally require:

1. A confirmed diagnosis of type 2 diabetes (ICD-10 E11.x), supported by HbA1c documentation.
2. Evidence that metformin was tried and either failed to achieve glycemic targets, was contraindicated (typically eGFR <30 mL/min/1.73m² or documented intolerance), or caused adverse effects.
3. The prescriber must be a licensed physician, NP, or PA operating within their scope of practice.

For the heart failure indication, the relevant DAPA-HF trial (N=4,744) published in the New England Journal of Medicine in 2019 demonstrated that dapagliflozin 10 mg once daily reduced the composite of worsening heart failure or cardiovascular death by 26% versus placebo (hazard ratio 0.74; 95% CI 0.65, 0.85; P<0.001) [4]. UHC's medical policy for HF coverage typically requires documentation of LVEF measurement and a diagnosis code consistent with heart failure. The EMPEROR-Reduced and EMPEROR-Preserved trials further shaped prescribing norms, though those studies examined empagliflozin rather than dapagliflozin [5].

For the CKD indication, the DAPA-CKD trial (N=4,304) showed a 39% relative risk reduction in the composite of sustained eGFR decline of at least 50%, end-stage kidney disease, or renal or cardiovascular death (hazard ratio 0.61; 95% CI 0.51, 0.72; P<0.001) [6]. UHC policies for CKD coverage commonly require a baseline eGFR value between 25 and 75 mL/min/1.73m² and a urine albumin-to-creatinine ratio (UACR) above 200 mg/g, consistent with the DAPA-CKD enrollment criteria.

The prescriber's office submits the PA using UHC's online portal (availity.com or directly through the UHC Provider Portal). Turnaround is up to 72 hours for standard requests and 24 hours for urgent requests under most state prompt-pay and utilization management laws [7].

Does UnitedHealthcare Require Step Therapy Before Farxiga?

Step therapy is common for the type 2 diabetes indication and less consistently applied to the heart failure and CKD indications. For T2D, most UHC commercial formularies require a documented trial of at least one generic first-line agent, almost always metformin, before Farxiga will be approved. Some plans also require a trial of a generic sulfonylurea or a generic DPP-4 inhibitor.

The American Diabetes Association's 2024 Standards of Care acknowledge SGLT2 inhibitors as preferred add-on therapy in patients with T2D who have established cardiovascular disease, heart failure, or CKD, regardless of baseline HbA1c [8]. That language can be used by prescribers to argue that step therapy requirements are clinically inappropriate for certain high-risk patients. Specifically, ADA states: "In patients with type 2 diabetes and established cardiovascular disease, or indicators of high cardiovascular risk, established kidney disease, or heart failure, an SGLT2 inhibitor... is recommended as part of the glucose-lowering regimen independent of baseline HbA1c" [8].

Step therapy exemptions may apply when:

• The patient has an eGFR <30, making metformin contraindicated.
• The patient has a documented allergy or intolerance to first-line agents.
• A cardiologist or nephrologist documents clinical urgency.
• The patient is transitioning from a previous plan that already approved Farxiga (continuity-of-care exception).

The Improving Seniors' Timely Access to Care Act of 2022 (federal law) reduced some step therapy burdens for Medicare Advantage plans, though commercial plan rules still vary significantly by employer contract [9].

How to Get UnitedHealthcare Prior Authorization Approved for Farxiga

Approval rates improve when the prescriber's office sends a complete, well-documented PA packet on the first submission. The following checklist reflects what UHC clinical reviewers are looking for:

For type 2 diabetes:

• Recent HbA1c (within 6 months), ideally above 7.0% despite current therapy.
• Documented metformin trial with dates, dose, duration, and outcome (or contraindication rationale with supporting eGFR lab).
• Prescriber attestation that Farxiga is being prescribed for T2D management.

For heart failure:

• Echocardiogram or imaging report documenting LVEF.
• ICD-10 code I50.x with documentation of NYHA functional class.
• Any prior HF hospitalizations or ED visits (strengthens medical necessity).

For CKD:

• eGFR result (ideally two values at least 90 days apart to confirm chronicity).
• UACR result.
• Nephrology or primary care note confirming CKD stage.

The KDIGO 2022 Clinical Practice Guideline for Diabetes Management in CKD gives dapagliflozin a Grade 1A recommendation for patients with T2D and CKD who have an eGFR of at least 25 mL/min/1.73m² [10]. Including this guideline reference in the PA letter often accelerates approval.

How to Appeal a UnitedHealthcare Denial of Farxiga

UnitedHealthcare uses a two-level internal appeal process before an external independent review organization (IRO) becomes available. The timeline and process are:

Level 1 internal appeal: Submit within 180 days of the denial notice. UHC must respond within 30 days for prospective (pre-service) appeals or 60 days for retrospective (post-service) appeals. Include a prescriber letter of medical necessity, relevant lab work, and any applicable guideline citations.

Level 2 internal appeal: If Level 1 fails, you have another 180-day window. The Level 2 review panel must include clinicians who were not involved in the Level 1 decision.

External IRO review: After exhausting internal appeals (or after 30 days without a decision on a Level 1 appeal), members of fully insured plans can request external review through the state insurance commissioner or directly through UHC. IRO decisions are binding on the insurer under the ACA's external review provisions [11].

Expedited appeal: For urgent situations, such as a patient currently hospitalized with heart failure who needs Farxiga initiated before discharge, UHC must respond to an expedited appeal within 72 hours [12].

The prescriber's letter of medical necessity is the single most important document in the appeal package. It should cite specific trial data. For HF patients, referencing the DAPA-HF trial result (26% relative risk reduction in the primary composite endpoint; P<0.001) alongside the ACC/AHA 2022 Heart Failure Guideline's Class I recommendation for SGLT2 inhibitors gives reviewers limited clinical ground to sustain a denial [13].

The HHS Office of Inspector General's 2022 report on Medicare Advantage prior authorization found that 75% of denied services met Medicare coverage rules, suggesting that many initial denials are overturned on appeal [14]. While that figure applies to Medicare Advantage rather than commercial UHC plans, it reflects a broader pattern: well-documented appeals frequently succeed.

How Much Does Farxiga Cost Without or With UnitedHealthcare Coverage?

Without insurance, Farxiga 10 mg carries a list price of approximately $620 per month for a 30-tablet supply. That list price has held relatively stable since 2022 because AstraZeneca has used it as the basis for rebate negotiations with pharmacy benefit managers.

With UHC Tier 3 coverage after your deductible is met, your cost typically falls to $60, $100 per 30-day fill. Plans that apply the deductible to brand drugs first may leave you paying the full $620 until your deductible resets, particularly early in the plan year.

The AstraZeneca Farxiga Savings Card can bring the monthly cost down to $0 for eligible commercially insured patients who meet income and eligibility requirements [15]. Patients on Medicare, Medicaid, or any federal- or state-funded program are not eligible for the manufacturer savings card. You can enroll at farxiga.com/savings or through your prescriber's office.

GoodRx and similar discount programs can offer cash prices around $500, $580 per month for brand Farxiga at major pharmacy chains. For generic dapagliflozin (available as of 2025), GoodRx prices may drop below $100 per month at some pharmacies, though availability varies by region.

The table below outlines the recommended cost-optimization path based on your insurance status. A HealthRX clinician developed this decision sequence based on UHC formulary data and AstraZeneca patient assistance program terms reviewed in Q1 2025.

Cost-optimization sequence for Farxiga on UHC:

1. Confirm your formulary tier and deductible status through MyUHC or your benefits card.
2. Ask your prescriber to submit a PA with complete documentation on the first attempt.
3. If denied, apply for the AstraZeneca savings card immediately while your prescriber files a Level 1 appeal.
4. If two internal appeals fail, request external IRO review through your state insurance commissioner.
5. If all coverage pathways fail, ask your prescriber whether generic dapagliflozin is clinically appropriate for your indication and check GoodRx pricing at multiple local pharmacies.

Is Farxiga Covered by UnitedHealthcare for Heart Failure Specifically?

Farxiga received FDA approval for HFrEF in May 2020 based on the DAPA-HF trial, and for HFpEF in August 2022 based on the DELIVER trial (N=6,263), in which dapagliflozin reduced the risk of worsening heart failure or cardiovascular death by 18% versus placebo (hazard ratio 0.82; 95% CI 0.73, 0.92; P<0.001) [16][17].

UHC commercial plans cover both HF indications with PA. The 2022 AHA/ACC/HFSA Heart Failure Guideline gives SGLT2 inhibitors a Class IIa recommendation for HFpEF and a Class I recommendation for HFrEF [13]. Citing the Class I guideline status in the PA form or appeal letter is particularly effective because it signals to the medical reviewer that denial would contradict major society guidance.

Cardiologists submitting PAs for heart failure patients should include: the echocardiogram report showing LVEF, the most recent BNP or NT-proBNP value, NYHA classification, and any hospitalization records within the preceding 12 months. Higher NT-proBNP values and recent hospitalization strongly support medical necessity.

Is Farxiga Covered by UnitedHealthcare for Chronic Kidney Disease?

Yes. UHC covers dapagliflozin for CKD with PA in patients whose eGFR falls within the approved range. The DAPA-CKD trial enrolled patients with eGFR 25 to 75 mL/min/1.73m², so UHC's criteria mirror that range. Patients with UACR above 200 mg/g had the greatest absolute benefit in DAPA-CKD, and that threshold often appears in UHC's CKD coverage policy language [6].

The KDIGO 2022 guideline explicitly states: "We recommend treating patients with T2D and CKD with a SGLT2 inhibitor if eGFR is ≥25 mL/min/1.73m²" [10]. Nephrologists who include this language in a PA or appeal letter give UHC medical reviewers a clear guideline basis for approval.

One nuance: Farxiga's glucose-lowering effect diminishes as eGFR falls, and it provides little glycemic benefit below eGFR 45. UHC coverage for CKD applies even when the primary goal is nephroprotection rather than glycemic control, which aligns with FDA labeling since the 2021 CKD approval was independent of diabetes status [2].

Does UnitedHealthcare Cover Farxiga for Weight Loss?

No. Farxiga is not FDA-approved for weight loss, and UHC does not cover it for that indication. Dapagliflozin produces modest body weight reduction as a secondary effect, roughly 2 to 3 kg in clinical trials, but this is an off-label use. UHC's coverage policies follow FDA-approved indications [18].

Patients seeking covered pharmacologic weight management should ask their prescriber about semaglutide 2.4 mg (Wegovy), which is FDA-approved for chronic weight management and covered under some UHC plans with separate PA criteria. In STEP-1 (N=1,961), semaglutide 2.4 mg produced 14.9% mean body weight loss at 68 weeks versus 2.4% with placebo (P<0.001) [19].

UnitedHealthcare Medicare Advantage and Farxiga

Medicare Advantage plan formularies differ from commercial formularies. UHC Medicare Advantage plans frequently place Farxiga at Tier 3 or Tier 4, with PA requirements similar to commercial plans but governed by CMS rules rather than state insurance law. The Inflation Reduction Act of 2022 capped Medicare Part D out-of-pocket costs at $2,000 per year starting in 2025, which meaningfully reduces catastrophic-phase costs for patients taking a brand drug like Farxiga [20].

Medicare Advantage members with CKD or heart failure should specifically ask their plan whether Farxiga qualifies for the Part D Senior Savings Model or any preferred pharmacy network discount. Manufacturer savings cards are not available to Medicare enrollees, but the AstraZeneca AZ&Me patient assistance program provides free medication to qualifying low-income patients regardless of insurance status [15].