Does Affinity Health Plan Cover Farxiga?

What Is Farxiga and Why Does Coverage Matter?

Farxiga (dapagliflozin) is a sodium-glucose cotransporter-2 (SGLT2) inhibitor manufactured by AstraZeneca. The FDA approved it in January 2014 for type 2 diabetes mellitus (T2D), and subsequent approvals in 2020 and 2021 expanded its label to heart failure with reduced ejection fraction (HFrEF) and chronic kidney disease (CKD), respectively [1]. Coverage matters because the drug's list price exceeds $550 per month, making insurance authorization the difference between a patient filling or abandoning a prescription.

Clinical Conditions Farxiga Treats

Dapagliflozin carries three distinct FDA-approved indications:

1. Type 2 diabetes, to improve glycemic control alongside diet and exercise.
2. Heart failure with reduced ejection fraction, to reduce the risk of cardiovascular death and worsening heart failure hospitalization, regardless of diabetes status.
3. Chronic kidney disease, to reduce the risk of sustained eGFR decline, end-stage kidney disease, cardiovascular death, and hospitalization.

Each indication may trigger a different prior authorization pathway at Affinity Health Plan. A patient with CKD and no T2D, for example, must submit documentation of eGFR and urine albumin-to-creatinine ratio, not just HbA1c.

Why SGLT2 Inhibitors Are Guideline-Recommended

The 2023 American Diabetes Association (ADA) Standards of Care state that SGLT2 inhibitors are recommended for patients with T2D and established cardiovascular disease, CKD (eGFR <60 mL/min/1.73 m² or albuminuria), or heart failure, independent of background glucose control [2]. The ADA guideline language reads: "For patients with type 2 diabetes and established CVD or indicators of high CVD risk, an SGLT2 inhibitor with demonstrated CVD benefit is recommended." Because Affinity Health Plan participates in Medicaid managed care in New York, it must align its formulary with Medicaid rules, yet it retains discretion over tier placement and prior authorization criteria.

How Affinity Health Plan Structures Its Drug Formulary

Affinity Health Plan uses a tiered formulary system across its Medicaid Managed Care (MMC), Child Health Plus (CHP), and Essential Plan (EP) product lines. Farxiga generally sits at Tier 3 (preferred brand) or Tier 4 (non-preferred brand), depending on the specific contract year and product line.

Formulary Tiers Explained

| Tier | Category | Typical Member Cost-Share | |------|----------|--------------------------| | 1 | Generic | $0-$3 copay | | 2 | Preferred generic | $5-$10 copay | | 3 | Preferred brand | $35-$50 copay | | 4 | Non-preferred brand | $60-$100 copay | | 5 | Specialty | 20-33% coinsurance |

Medicaid members in New York typically pay $0-$3 per prescription under state cost-sharing caps, regardless of tier. Commercial Essential Plan members face higher cost-sharing that tracks the tier structure above.

How to Check the Current Formulary

Affinity Health Plan publishes its formulary on its member portal at affinityplan.org. The fastest verification method is to call the pharmacy benefits number on the back of your insurance card and ask the representative to check the drug's formulary status for your specific plan ID. Your pharmacist can also run a real-time eligibility check before you pick up the prescription.

Prior Authorization Requirements for Farxiga at Affinity

Prior authorization (PA) is almost certain to be required. PA criteria for Farxiga at most Managed Medicaid plans in New York include documentation that the patient has a confirmed diagnosis of T2D (ICD-10: E11.xx), HFrEF (ICD-10: I50.2x), or CKD (ICD-10: N18.x), plus evidence of clinical need. Affinity follows the New York State Department of Health preferred drug list guidance, which places SGLT2 inhibitors behind metformin as first-line therapy for uncomplicated T2D [3].

Step Therapy Requirements

For T2D, Affinity typically requires:

• Step 1: Metformin (unless contraindicated due to eGFR <30 or GI intolerance).
• Step 2: A sulfonylurea (glipizide, glimepiride) or a DPP-4 inhibitor (sitagliptin) for at least 90 days.
• Step 3: Approval of Farxiga if HbA1c remains above the individualized target.

Patients with established cardiovascular disease or CKD may qualify for a step-therapy exception, because the ADA guidelines and the 2022 AHA/ACC Heart Failure guidelines both recommend SGLT2 inhibitors for those populations without requiring prior failure of older agents [4].

How to Submit a Prior Authorization Request

Your prescribing clinician's office submits the PA through Affinity's online portal, by fax, or via CoverMyMeds. The PA packet should include:

• Current HbA1c (for T2D indication) or most recent eGFR and UACR (for CKD indication) or echocardiogram with ejection fraction <40% (for HFrEF).
• A note documenting contraindication or failure of step-therapy agents, if applicable.
• ICD-10 diagnosis codes.
• Prescriber NPI and DEA numbers.

Affinity must respond to a standard PA request within 3 business days and an expedited request within 24 hours under federal Medicaid managed care regulations at 42 CFR 438.210.

What the Clinical Evidence Says About Dapagliflozin

Understanding the evidence base helps clinicians write stronger PA letters and helps patients understand why their doctor is requesting this specific drug.

DECLARE-TIMI 58 Trial (Cardiovascular Outcomes)

The DECLARE-TIMI 58 trial enrolled 17,160 patients with T2D and either established atherosclerotic cardiovascular disease or multiple risk factors. Dapagliflozin 10 mg reduced the composite of cardiovascular death or hospitalization for heart failure by 17% compared with placebo (4.9% vs. 5.8%; hazard ratio 0.83; 95% CI 0.73-0.95; P<0.001 for non-inferiority and P=0.005 for superiority) [5]. This trial is the primary evidence Affinity reviewers should weigh when evaluating a PA for a patient with T2D and cardiovascular risk factors.

DAPA-HF Trial (Heart Failure)

The DAPA-HF trial enrolled 4,744 patients with HFrEF (ejection fraction <40%), 45% of whom did not have diabetes. Dapagliflozin 10 mg reduced the primary composite endpoint of worsening heart failure or cardiovascular death by 26% relative to placebo (16.3% vs. 21.2%; hazard ratio 0.74; 95% CI 0.65-0.85; P<0.001) [6]. This trial is the foundation for the 2020 FDA approval in HFrEF and for PA approvals in patients without diabetes who have heart failure.

DAPA-CKD Trial (Chronic Kidney Disease)

The DAPA-CKD trial enrolled 4,304 patients with CKD (eGFR 25-75 mL/min/1.73 m²) and albuminuria, 32% of whom did not have T2D. Dapagliflozin 10 mg reduced the primary composite of a sustained decline in eGFR of <50%, end-stage kidney disease, or death from renal or cardiovascular causes by 39% (9.2% vs. 14.5%; hazard ratio 0.61; 95% CI 0.51-0.73; P<0.001) [7]. The trial was stopped early due to clear efficacy.

The three-indication framework above maps directly to the PA letter your physician should write. Documenting which trial population your patient resembles, with specific lab values that mirror the enrollment criteria, gives the Affinity medical reviewer a clear basis for approval.

What Farxiga Costs With and Without Affinity Coverage

Without insurance, a 30-day supply of Farxiga 10 mg carries a list price of approximately $556-$600 at major retail pharmacies as of 2025. With Affinity Medicaid coverage and an approved PA, most Medicaid members pay $0-$3 per fill under New York State cost-sharing rules. Commercial Essential Plan members with Tier 3 placement typically pay $35-$50 per fill after meeting their deductible.

Manufacturer Savings Programs

AstraZeneca offers the AZ&Me Prescription Savings Program for commercially insured patients who meet income criteria, potentially reducing the cost to $0 per month. Patients without insurance may also qualify for the AZ&Me patient assistance program, which provides Farxiga at no cost for individuals below 400% of the federal poverty level. More information is available directly from AstraZeneca or through NeedyMeds.org.

GoodRx and Pharmacy Discount Cards

GoodRx coupons for dapagliflozin 10 mg (30 tablets) frequently list prices of $400-$480 at major chains. These discount card prices cannot be combined with insurance; a member must choose one or the other at the point of sale. For Affinity Medicaid members, the insurance route is almost always cheaper.

What to Do If Affinity Denies Coverage for Farxiga

A denial is not the end of the road. New York State law and federal Medicaid regulations give members specific rights.

Step 1: Request a Formulary Exception

Your prescriber submits a formulary exception request arguing that no formulary alternative is clinically appropriate. Under 42 CFR 438.210(b), Affinity must grant a formulary exception when an alternative drug on the formulary would be clinically contraindicated or when the patient has already tried and failed formulary alternatives.

Step 2: File an Internal Appeal

If the formulary exception is denied, request a formal internal appeal within 60 days of the denial notice. Affinity must respond within 30 days (standard) or 72 hours (expedited) under New York State Insurance Law and 42 CFR 438.408.

Step 3: Request an External Appeal or State Fair Hearing

Medicaid members who exhaust the internal appeal process may request a State Fair Hearing through the New York State Office of Temporary and Disability Assistance (OTDA) or an independent external appeal through the New York State Department of Financial Services. Either route allows an independent review of Affinity's decision.

Step 4: Contact Your Physician's Office for Peer-to-Peer Review

Affinity's medical director must offer a peer-to-peer review to any prescriber who requests one after a PA denial. A 15-minute phone call between the prescribing cardiologist or endocrinologist and Affinity's reviewing physician frequently resolves denials that a written PA did not, especially when the prescriber cites DECLARE-TIMI 58 [5] or DAPA-CKD [7] data directly.

Alternatives to Farxiga That Affinity May Cover at Lower Tiers

If the prior authorization is denied and appeals are exhausted, several clinical alternatives exist within the SGLT2 class or adjacent drug classes.

Other SGLT2 Inhibitors

• Empagliflozin (Jardiance), approved for T2D, HFrEF, HFpEF, and CKD. The EMPA-REG OUTCOME trial (N=7,020) showed a 38% reduction in cardiovascular death in patients with T2D and established CVD [8]. Jardiance may sit at a different formulary tier at Affinity; check the current formulary.
• Canagliflozin (Invokana), approved for T2D and CKD. CREDENCE (N=4,401) showed a 30% reduction in the primary composite renal and cardiovascular endpoint vs. Placebo [9].
• Ertugliflozin (Steglatro), approved for T2D only; less cardiovascular outcome data than the above.

GLP-1 Receptor Agonists

For patients whose primary need is glycemic control or weight management and who cannot obtain an SGLT2 inhibitor, GLP-1 receptor agonists (semaglutide, liraglutide, dulaglutide) are guideline-recommended alternatives. STEP-1 (N=1,961) showed semaglutide 2.4 mg produced 14.9% mean weight loss at 68 weeks vs. 2.4% for placebo [10]. Affinity's formulary coverage for GLP-1 agents varies and also commonly requires PA.

Practical Steps to Get Farxiga Covered by Affinity Health Plan

The sequence below is the most efficient path for most patients.

1. Ask your physician to verify Farxiga's formulary status for your exact plan ID before submitting the prescription. One phone call saves days.
2. Request that your physician's office submit a PA with lab documentation. Send HbA1c, eGFR, UACR, and ejection fraction where applicable.
3. If step therapy applies, document which prior agents were tried, the duration, and the reason for discontinuation.
4. If denied, pursue peer-to-peer review before filing a formal appeal. Peer-to-peer calls resolve many denials in 24-48 hours.
5. While the PA is pending, ask AstraZeneca about a bridge supply or check eligibility for the AZ&Me program.
6. If all else fails at Affinity, ask your prescriber whether empagliflozin or canagliflozin would be an acceptable clinical substitute, since tier placement differs across the SGLT2 class.

The ADA's 2023 Standards of Care note that "access to recommended therapies is often limited by formulary restrictions" and call on health plans to "minimize utilization management barriers for evidence-based therapies" [2]. Bringing that guideline language directly into your PA letter signals to Affinity's medical reviewer that the request is rooted in current national standards, not physician preference alone.