Does Amerigroup Cover Farxiga?

What Is Farxiga and Why Does Coverage Matter?

Farxiga is the brand name for dapagliflozin, a sodium-glucose cotransporter-2 (SGLT2) inhibitor approved by the FDA for three distinct indications. Each indication carries its own coverage pathway through Medicaid managed care plans like Amerigroup. Getting that coverage right can mean the difference between a $10 copay and a $500+ cash-pay bill.

FDA-Approved Indications for Dapagliflozin

The FDA granted dapagliflozin its original approval for type 2 diabetes mellitus in January 2014 [1]. Two subsequent approvals followed: heart failure with reduced ejection fraction (HFrEF) in 2020 [2], and chronic kidney disease (CKD) stages 2 through 4 in 2021 [3]. The DAPA-HF trial (N=4,744) showed dapagliflozin reduced the composite of worsening heart failure or cardiovascular death by 26% versus placebo (hazard ratio 0.74; 95% CI 0.65 to 0.85; P<0.001) [4]. The DAPA-CKD trial (N=4,304) demonstrated a 39% relative risk reduction in the composite renal and cardiovascular endpoint (HR 0.61; 95% CI 0.51 to 0.72; P<0.001) [5].

These outcomes data matter for your prior authorization (PA) appeal because Amerigroup medical directors weigh clinical trial evidence when reviewing non-preferred brand requests.

How SGLT2 Inhibitors Fit Into Diabetes Guidelines

The American Diabetes Association's 2024 Standards of Care recommend SGLT2 inhibitors as preferred add-on agents for patients with type 2 diabetes who also have atherosclerotic cardiovascular disease, heart failure, or CKD, independent of A1C control [6]. The ADA states: "For patients with type 2 diabetes and established cardiovascular disease or high cardiovascular risk, an SGLT2 inhibitor or GLP-1 receptor agonist with demonstrated cardiovascular benefit is recommended" [6]. Amerigroup PA criteria often mirror ADA guidelines, so citing this recommendation in an appeal letter carries real weight.

How Amerigroup Formularies Work

Amerigroup operates Medicaid managed care plans in roughly 18 states, each with a state-specific formulary approved by that state's Medicaid agency. A drug covered in Georgia may sit on a different tier in Tennessee or Texas. Understanding the tier structure is the first step toward predicting your out-of-pocket cost.

Tier Placement for Farxiga

Across Amerigroup state plans reviewed for 2024, Farxiga most commonly appears on Tier 3 (non-preferred brand) or Tier 4 (specialty/non-preferred brand), depending on the state contract. Generic metformin sits on Tier 1. Jardiance (empagliflozin) occupies a preferred brand position (Tier 2) on some Amerigroup formularies because AstraZeneca and Eli Lilly negotiate rebate contracts separately with each state Medicaid program [7].

Prior Authorization Criteria

PA criteria published by state Medicaid agencies typically require:

1. A diagnosis of type 2 diabetes mellitus (ICD-10 E11.x), HFrEF (ICD-10 I50.2x), or CKD stages 2 to 4 (ICD-10 N18.2, N18.4).
2. Documentation that the patient tried and failed, or has a contraindication to, metformin at the maximum tolerated dose for at least 90 days.
3. A current A1C result (for the diabetes indication) or an ejection fraction measurement (for HFrEF).
4. Prescriber attestation that the requested dose (5 mg or 10 mg) matches the FDA-approved indication.

Missing any single element is the most common reason for initial PA denial. The FDA prescribing information for dapagliflozin specifies that the 10 mg dose is used for diabetes and CKD, while either 5 mg or 10 mg may be used for HFrEF [1].

Step Therapy Requirements

Step therapy means Amerigroup may require you to try a preferred formulary SGLT2 inhibitor, such as empagliflozin, before approving Farxiga. If your physician has a clinical reason to prefer dapagliflozin specifically (for example, the patient is already stable on it, or the DAPA-CKD data drove the prescribing decision), that rationale should appear in the PA request. The Centers for Medicare and Medicaid Services (CMS) issued guidance in 2023 affirming that step therapy exceptions must be granted when clinical evidence supports a specific drug [7].

How to Check Your Specific Amerigroup Plan

Coverage varies enough that a general answer only gets you partway there. You need to verify your own plan's formulary directly.

Step 1: Use the Amerigroup Online Formulary Tool

Amerigroup posts state-specific formulary PDFs and drug look-up tools on its member portal. Log in at the Amerigroup member website, enter "dapagliflozin" or "Farxiga," and select the 2024 plan year. The result will show tier, PA requirement, quantity limits, and step therapy flags.

Step 2: Call Member Services

The phone number on the back of your Amerigroup ID card connects to a pharmacy benefits representative who can confirm real-time formulary status. Ask specifically: "Is dapagliflozin 10 mg on the formulary for my plan, and does it require prior authorization?" Write down the representative's name and the call reference number.

Step 3: Have Your Prescriber Submit the PA

Your prescriber (or their office staff) submits the PA through CoverMyMeds, Surescripts, or by fax to the Amerigroup pharmacy prior authorization line. Amerigroup is required by federal Medicaid regulations to respond to standard PA requests within 72 hours and urgent requests within 24 hours [8].

What Farxiga Costs on Amerigroup

For Medicaid members, federal law caps cost-sharing. Under 42 CFR § 447.54, nominal copayments for non-preferred drugs may not exceed $4 for preferred drugs or $8 for non-preferred drugs for most Medicaid beneficiaries [9]. A small subset of Medicaid members, including those with incomes above 150% of the federal poverty level on expansion plans, may face slightly higher copays depending on the state.

With Prior Authorization Approved

Once PA is approved, your cost at the pharmacy for a 30-day supply of Farxiga 10 mg will typically be $0 to $8 under Medicaid cost-sharing rules. AstraZeneca also operates an Amerigroup-compatible patient assistance pathway for members who face gaps in coverage [10].

Without PA or During an Appeal

If you are waiting on a PA decision or appealing a denial, you can ask your prescriber for a 30-day emergency supply bridge. Some states mandate a pharmacist override period of 72 hours for medically necessary drugs while the PA is pending. Check your state Medicaid agency's rules, as this right varies [8].

Cash-Pay Comparison

Without insurance, a 30-day supply of brand-name Farxiga 10 mg retails for approximately $560, $610 at major U.S. Pharmacies as of mid-2024. No FDA-approved generic dapagliflozin exists as of the publication date of this article, though AstraZeneca's exclusivity is expected to expire in the mid-2020s.

Prior Authorization Step-by-Step Submission Guide

Submitting a clean PA request the first time is faster than appealing a denial. The following framework reflects standard Amerigroup Medicaid PA requirements across multiple states.

Required Clinical Documentation Checklist

• Office visit note dated within the past 90 days confirming the primary diagnosis (type 2 diabetes, HFrEF, or CKD).
• Lab results: A1C within 6 months for diabetes; eGFR and urine albumin-to-creatinine ratio (UACR) within 6 months for CKD; echocardiogram with ejection fraction for HFrEF.
• Pharmacy history showing metformin fill dates and doses (usually obtained from the Amerigroup claims history or state prescription drug monitoring program).
• Letter of medical necessity signed by the prescribing physician citing the clinical trial evidence (DAPA-HF [4] or DAPA-CKD [5]) if applicable.
• The correct diagnosis code and NDC number for the specific Farxiga strength requested.

Submitting Through CoverMyMeds

CoverMyMeds integrates directly with Amerigroup's PA processing system. The prescriber selects Farxiga from the drug list, answers the clinical questions (diagnosis, prior therapy, lab values), and electronically submits. The system populates the Amerigroup-specific PA form automatically [11].

Timeline to Expect

Standard decisions arrive within 3 business days. Urgent PA requests, defined as situations where waiting the standard timeframe could seriously jeopardize the member's life or health, must be adjudicated within 24 hours under 42 CFR § 438.210 [8].

What to Do If Amerigroup Denies Coverage

A denial is not the end of the road. Federal Medicaid managed care regulations give members specific appeal rights under 42 CFR § 438.400 et seq. [8].

Step 1: Request the Denial in Writing

Amerigroup must provide a written Notice of Action explaining the reason for denial. Common denial reasons include: drug not on formulary, step therapy not completed, PA criteria not met, or missing documentation.

Step 2: File an Internal Appeal

File the internal appeal within 60 days of the denial notice (or the timeframe stated on your Notice of Action, whichever is shorter). Submit the clinical documentation checklist above plus a letter from the prescriber specifically rebutting the denial reason. If the denial cited step therapy not completed, include a clinical explanation for why the preferred alternative is contraindicated or clinically inappropriate for this patient.

Step 3: Request an Expedited Appeal

If waiting for the standard 30-day appeal resolution would cause serious harm, request an expedited appeal. Amerigroup must resolve expedited appeals within 72 hours under federal Medicaid managed care rules [8].

Step 4: State Fair Hearing

If the internal appeal is denied, the member has the right to request a state Medicaid fair hearing. An administrative law judge, independent of Amerigroup, reviews the case. The ADA has documented that SGLT2 inhibitors meet the clinical threshold for medical necessity in patients with type 2 diabetes and cardiovascular comorbidities [6], and citing this in a fair hearing can strengthen the case.

Step 5: External Independent Review

Some states also allow external independent review organizations (IROs) to review Medicaid managed care denials. IRO reviewers are board-certified physicians in the relevant specialty. A 2022 analysis published in JAMA found that external reviews overturned health plan decisions in approximately 39% of cases reviewed [12].

Clinical Evidence Supporting Medical Necessity for Farxiga

When building an appeal, the clinical evidence base for dapagliflozin is among the strongest of any SGLT2 inhibitor. Here is the trial-level data your prescriber can cite directly.

DECLARE-TIMI 58 (Type 2 Diabetes, Cardiovascular Outcomes)

The DECLARE-TIMI 58 trial enrolled 17,160 patients with type 2 diabetes and either established atherosclerotic cardiovascular disease or multiple cardiovascular risk factors. Dapagliflozin reduced the rate of hospitalization for heart failure or cardiovascular death by 17% compared to placebo (HR 0.83; 95% CI 0.73 to 0.95; P=0.005) [13]. This is the trial that supports dapagliflozin use in the broadest population of type 2 diabetes patients.

DAPA-HF (Heart Failure with Reduced Ejection Fraction)

As cited above, DAPA-HF (N=4,744) demonstrated a 26% reduction in the composite outcome of worsening heart failure or cardiovascular death [4]. The trial included patients with and without type 2 diabetes, establishing benefit across both populations. The FDA expanded dapagliflozin's label to include HFrEF in May 2020 [2].

DAPA-CKD (Chronic Kidney Disease)

DAPA-CKD (N=4,304) was stopped early by the data safety monitoring board because of overwhelming efficacy. Dapagliflozin reduced the composite of sustained eGFR decline of 50% or more, end-stage kidney disease, or renal or cardiovascular death by 39% [5]. The FDA granted approval for this indication in April 2021 [3].

SGLT2 Inhibitors in ADA and ACC/AHA Guidelines

The 2024 ACC/AHA guidelines on chronic coronary disease list SGLT2 inhibitors as Class I recommended therapy for patients with type 2 diabetes and established coronary artery disease [14]. The American College of Cardiology states: "SGLT2 inhibitors are recommended to reduce cardiovascular events in patients with type 2 diabetes and established cardiovascular disease" [14]. Amerigroup PA reviewers reference national guidelines, and a Class I recommendation from ACC/AHA is among the strongest available clinical arguments.

Alternative SGLT2 Inhibitors on Amerigroup Formularies

If Farxiga is denied or placed on a tier that makes it cost-prohibitive, these alternatives may appear on a preferred tier for your specific Amerigroup state plan.

Jardiance (Empagliflozin)

Empagliflozin is FDA-approved for type 2 diabetes, HFrEF, heart failure with preserved ejection fraction (HFpEF), and CKD [15]. The EMPA-REG OUTCOME trial (N=7,020) showed empagliflozin reduced cardiovascular death by 38% (HR 0.62; 95% CI 0.49 to 0.77; P<0.001) in patients with type 2 diabetes and established cardiovascular disease [16]. Some Amerigroup state plans place empagliflozin on Tier 2 due to formulary negotiations, making it a lower-cost option if it is clinically appropriate.

Invokana (Canagliflozin)

Canagliflozin is FDA-approved for type 2 diabetes and CKD in patients with type 2 diabetes and albuminuria [17]. The CREDENCE trial (N=4,401) showed canagliflozin reduced the risk of end-stage kidney disease by 32% (HR 0.68; 95% CI 0.54 to 0.86; P=0.002) [18]. Canagliflozin carries an FDA boxed warning for lower limb amputation risk, which your prescriber should weigh when considering it as an alternative [17].

Steglatro (Ertugliflozin)

Ertugliflozin is FDA-approved for type 2 diabetes only. It has less cardiovascular outcomes data than dapagliflozin, empagliflozin, or canagliflozin, and is generally a third-line alternative within the SGLT2 class [19].

Special Populations and Coverage Considerations

Patients with CKD

Dapagliflozin's FDA-approved CKD indication covers patients with eGFR 25 mL/min/1.73 m² or higher and UACR 200 mg/g or higher [3]. Farxiga may be used for CKD even in patients without type 2 diabetes, a distinction that matters for PA submissions. Patients with CKD and no diabetes diagnosis should have ICD-10 N18.x coded as the primary diagnosis on the PA request, not an E11 code.

Dual-Eligible Medicare-Medicaid Members

Dual-eligible members (those enrolled in both Medicare and Medicaid) access Farxiga through Medicare Part D, not through Amerigroup's Medicaid pharmacy benefit. Medicare Part D formularies operate under different rules. The CMS Low-Income Subsidy (LIS, also called "Extra Help") reduces Part D cost-sharing significantly for qualifying dual-eligibles [20].

Pediatric Patients

The FDA has not approved dapagliflozin for patients under age 18 for the diabetes indication, and the CKD approval also excludes pediatric patients [1]. Amerigroup PA criteria reflect these restrictions, and requests for pediatric patients are likely to be denied on label grounds.

Farxiga Safety Profile: What Reviewers Look For

Amerigroup PA reviewers also consider whether the requested drug is appropriate given the member's comorbidities. Knowing the safety profile helps prescribers preempt denial on clinical appropriateness grounds.

Key Safety Warnings in the FDA Label

The FDA prescribing information for dapagliflozin includes warnings for diabetic ketoacidosis (DKA), particularly in off-label use in type 1 diabetes; urinary tract infections; genital mycotic infections; and Fournier's gangrene (necrotizing fasciitis of the perineum) [1]. The DKA warning is relevant because Amerigroup reviewers may flag requests for type 1 diabetes patients, where dapagliflozin is not FDA-approved.

Renal Dosing Considerations

Farxiga's glycemic efficacy diminishes at eGFR values below 45 mL/min/1.73 m², though the drug may still be used for its non-glycemic CKD indication at eGFR as low as 25 [1]. PA requests for the glycemic indication in patients with eGFR <45 should specify that the drug is being used for a non-glycemic indication if that is the clinical intent.

Frequently Asked Questions