Does Anthem Cover Farxiga? A Complete Insurance Guide

What Is Farxiga and Why Does Coverage Matter?

Farxiga is the brand name for dapagliflozin, a sodium-glucose cotransporter-2 (SGLT2) inhibitor manufactured by AstraZeneca. The FDA first approved it in January 2014 for glycemic control in type 2 diabetes, then expanded approval in 2020 for heart failure with reduced ejection fraction (HFrEF), in 2023 for heart failure with preserved ejection fraction (HFpEF), and also for chronic kidney disease (CKD) risk reduction [1]. Because it spans three serious chronic conditions, more patients are seeking coverage than ever before.

No FDA-approved generic exists for dapagliflozin as of early 2025 [2]. That single fact makes insurance coverage the primary driver of whether a patient can afford the drug. The list price for Farxiga runs approximately $550, $600 for a 30-day supply at most U.S. Retail pharmacies, putting it out of reach for most patients paying cash.

What SGLT2 Inhibitors Do Clinically

SGLT2 inhibitors block glucose reabsorption in the proximal tubule of the kidney, causing excess glucose to be excreted in urine. The DECLARE-TIMI 58 trial (N=17,160) demonstrated that dapagliflozin reduced the rate of hospitalization for heart failure or cardiovascular death by 17% compared to placebo in patients with type 2 diabetes (hazard ratio 0.83; 95% CI 0.73 to 0.95) [3]. The DAPA-CKD trial (N=4,304) showed a 39% reduction in the composite of sustained eGFR decline, end-stage kidney disease, or renal/CV death versus placebo [4].

These outcomes data matter for insurance purposes because payers increasingly use them to decide which drugs qualify for preferred tier placement.

Why the Indication on the Prescription Matters

Anthem and most other commercial payers evaluate Farxiga coverage separately by indication. A prescription written for type 2 diabetes may face different prior authorization (PA) criteria than one written for CKD or HFrEF. Providing the correct ICD-10 code on the PA request (E11.x for type 2 diabetes, N18.x for CKD, I50.x for heart failure) is one of the most common ways PA requests are approved on the first submission.

How Anthem's Formulary Works

Anthem uses a tiered formulary system. The specific tier assigned to Farxiga depends on whether your plan is a commercial group plan, an individual/family plan purchased on the ACA marketplace, a Medicare Advantage plan, or a Medicaid managed care plan. Anthem's pharmacy benefit is administered through IngenioRx (Anthem's own PBM), though some employer group plans contract separately [5].

Formulary Tiers at Anthem

Most Anthem commercial formularies include five tiers:

• Tier 1: Preferred generics (lowest cost)
• Tier 2: Non-preferred generics or preferred brands
• Tier 3: Preferred brand-name drugs
• Tier 4: Non-preferred brand-name drugs (highest standard copay)
• Tier 5: Specialty drugs

Farxiga typically sits at Tier 3 or Tier 4 on Anthem commercial plans. Empagliflozin (Jardiance) is sometimes placed at a lower tier because AstraZeneca and Eli Lilly compete for formulary position; whichever manufacturer negotiates better rebates in a given plan year may receive the preferred tier. You can confirm Farxiga's tier for your specific plan by logging into anthem.com and using the formulary search tool, or by calling the number on the back of your insurance card.

Step Therapy Requirements

Many Anthem plans impose step therapy, meaning you must try and "fail" one or more alternatives before Farxiga is approved. Common step requirements include:

1. Metformin (generic, Tier 1) for at least 90 days
2. A preferred SGLT2 inhibitor or GLP-1 receptor agonist if available on the formulary
3. Documentation that the alternatives were ineffective, contraindicated, or caused adverse effects

If your physician has a clinical reason to start Farxiga without stepping through alternatives, for example, a patient with advanced CKD where metformin is contraindicated, that rationale must appear in the PA request with supporting lab values (eGFR, HbA1c, serum creatinine).

Does Anthem Require Prior Authorization for Farxiga?

Yes, prior authorization is required on most Anthem commercial and Medicare Advantage plans. The PA process means your prescribing physician (or their office staff) must submit clinical documentation justifying Farxiga before Anthem will approve coverage [6].

What the PA Request Typically Needs

Anthem's IngenioRx PA criteria for Farxiga commonly include:

• Confirmed diagnosis with appropriate ICD-10 code
• HbA1c value (for diabetes indication, typically HbA1c <7% may not qualify without additional CKD or HF documentation)
• Documentation of prior drug trials (metformin, other agents)
• Current medication list showing Farxiga will be added or substituted
• Recent labs: eGFR, urine albumin-to-creatinine ratio (UACR) for CKD indication
• Physician attestation that alternatives are inadequate

PA approvals, when granted, are typically valid for 12 months. Renewal PAs are usually less burdensome if the patient has documented clinical benefit.

Timeline for PA Decisions

Under federal law (29 CFR 2590.712), urgent PA requests must be decided within 72 hours; non-urgent requests must be decided within 15 calendar days for medical benefits and within a timeframe set by state law for pharmacy benefits [7]. Many states, including California and New York (both large Anthem markets), have enacted additional prompt-pay and PA-timeline rules that may shorten this window.

What Anthem Covers Farxiga For: Approved Indications

Type 2 Diabetes

The original and most widely covered indication. Anthem commercial plans generally cover Farxiga for adults with type 2 diabetes whose HbA1c is not at goal on metformin alone or who have contraindications to first-line therapy. The FDA label states the recommended dose is 5 mg once daily, with the option to increase to 10 mg once daily for additional glycemic control [1].

Heart Failure (HFrEF and HFpEF)

The DAPA-HF trial (N=4,744) showed that dapagliflozin 10 mg once daily reduced the composite of worsening heart failure or cardiovascular death by 26% compared with placebo (HR 0.74; 95% CI 0.65 to 0.85; P<0.001) in patients with HFrEF, regardless of whether they had diabetes [8]. The DELIVER trial (N=6,263) extended this benefit to HFpEF, showing a 18% reduction in the primary composite endpoint (HR 0.82; 95% CI 0.73 to 0.92; P<0.001) [9].

Anthem's medical policy has been updated to reflect these indications, but PA requirements differ. For the heart failure indication, documentation of ejection fraction (echocardiogram report), NYHA class, and concurrent guideline-directed medical therapy (beta-blocker, ACE inhibitor/ARB/ARNI) is typically required.

Chronic Kidney Disease

The DAPA-CKD trial (N=4,304) showed dapagliflozin reduced the primary composite of eGFR decline, end-stage kidney disease, or renal/cardiovascular death by 39% (HR 0.61; 95% CI 0.51 to 0.72; P<0.001) [4]. The American Diabetes Association's 2024 Standards of Care recommend SGLT2 inhibitors for patients with CKD and an eGFR >20 mL/min/1.73m² (Grade A evidence) [10].

For coverage under the CKD indication, Anthem typically requires UACR >200 mg/g and eGFR between 25 to 75 mL/min/1.73m² at initiation, consistent with the DAPA-CKD inclusion criteria. Patients with eGFR <25 mL/min/1.73m² may face additional scrutiny because the drug was studied in a limited range at very low eGFR.

How Much Does Farxiga Cost With Anthem?

Your actual out-of-pocket cost depends on your plan's deductible, copay structure, and whether you have met your deductible for the year.

Typical Cost Scenarios

| Plan Type | Deductible Met | Typical Monthly Cost | |---|---|---| | Anthem commercial (Tier 3) | Yes | $45, $90 copay | | Anthem commercial (Tier 4) | Yes | $90, $200 copay | | Anthem commercial (any tier) | No | Up to full list price (~$560) | | Anthem Medicare Advantage | Varies | $47, $120 (Part D tier) | | Anthem Medicaid managed care | N/A | Usually $0, $4 copay |

AstraZeneca Savings Card

AstraZeneca's Farxiga Savings Card allows commercially insured patients who are not enrolled in government programs (Medicare, Medicaid, TRICARE) to pay as little as $10 per month for up to 24 months, subject to a monthly maximum savings cap [11]. This card stacks on top of Anthem coverage and can eliminate most or all of the copay during the savings card period.

Patients on Anthem Medicare Advantage are not eligible for the AstraZeneca savings card due to federal anti-kickback statute limitations, but may qualify for AstraZeneca's patient assistance program (AZ&ME) if their income is below 600% of the federal poverty level.

What to Do If Anthem Denies Farxiga Coverage

A denial is not the end of the road. Approximately 39 to 59% of commercial insurance prior authorization appeals are ultimately approved, according to a 2023 analysis of insurer-level data submitted to state regulators [12].

Step 1: Request a Detailed Denial Letter

Anthem must provide a written explanation of the specific clinical criteria your request did not meet. This letter is the foundation of your appeal.

Step 2: File an Internal Appeal

Your physician's office submits an internal appeal with additional documentation addressing the stated denial reasons. The appeal should include:

• Peer-reviewed literature supporting Farxiga for your specific indication (DAPA-HF, DAPA-CKD, DECLARE-TIMI 58 are directly relevant)
• A letter of medical necessity from your physician explaining why alternatives are inadequate
• Any relevant lab results, imaging, or specialist notes

Step 3: Request a Peer-to-Peer Review

Your physician can request a phone call with the Anthem medical director who reviewed the case. This peer-to-peer review is one of the most effective tools for overturning step-therapy denials. Physicians who present the specific trial data and clearly articulate why the patient cannot follow step therapy have a meaningfully higher approval rate.

Step 4: External Review

If the internal appeal fails, you have the right under the ACA to an independent external review by a third-party organization not affiliated with Anthem [13]. External reviewers overturn insurer decisions at rates that vary by condition, but the process is free to patients and is often the final step before litigation or state insurance commissioner complaints.

The HealthRX Insurance Navigation Framework for SGLT2 Inhibitor Coverage organizes these four steps into a single provider workflow. During review, the HealthRX medical team will insert the complete decision tree as an original figure.

Anthem Medicare Advantage and Farxiga (Part D Coverage)

Medicare Part D coverage of Farxiga through Anthem Medicare Advantage plans follows the CMS formulary guidelines. CMS requires all Part D plans to cover at least two drugs in each therapeutic class, and the SGLT2 class is well-represented. Farxiga appears on most Anthem Medicare Advantage formularies at Tier 3 (preferred brand) or Tier 4 (non-preferred brand).

The Part D coverage gap ("donut hole") was eliminated for most drugs beginning January 1, 2025, under the Inflation Reduction Act provisions, capping out-of-pocket drug spending at $2,000 per year for Medicare Part D enrollees [14]. This change meaningfully reduces the annual cost burden for Medicare patients taking Farxiga.

For the CKD indication specifically, CMS issued guidance in 2023 encouraging Part D plans to cover SGLT2 inhibitors with less restrictive PA criteria given the DAPA-CKD outcome data, though individual plan policies still vary [15].

Farxiga vs. Competing SGLT2 Inhibitors on Anthem Formularies

If Anthem denies Farxiga or places it on a high cost-sharing tier, your physician may consider these alternatives:

• Empagliflozin (Jardiance): Often on a preferred tier on Anthem plans where Eli Lilly has negotiated formulary placement. The EMPEROR-Reduced (N=3,730) and EMPEROR-Preserved (N=5,988) trials showed cardiovascular and renal outcomes data comparable to the DAPA program [16].
• Canagliflozin (Invokana): FDA-approved for type 2 diabetes and CKD. The CREDENCE trial (N=4,401) showed a 30% reduction in the primary renal composite endpoint [17]. Invokana carries an FDA boxed warning for lower limb amputation risk, which may affect patient and physician preference.
• Ertugliflozin (Steglatro): Approved for type 2 diabetes; less outcomes data compared to the above agents.

If your physician determines that Farxiga is specifically indicated (for example, because of HFpEF data from DELIVER that some competing agents lack), that clinical rationale strengthens the PA and appeal documentation.

Anthem Medicaid and Farxiga

Anthem administers Medicaid managed care programs in multiple states including Virginia, Georgia, Indiana, and others. Medicaid formularies are governed by state-specific preferred drug lists (PDLs). In most Anthem Medicaid plans, Farxiga is covered with minimal or no cost-sharing for enrollees, but PA requirements still apply for the heart failure and CKD indications. Medicaid copays are capped by federal law at nominal amounts (typically $1, $4 for brand drugs for most beneficiaries).

Practical Steps to Get Farxiga Covered by Anthem

1. Confirm your formulary. Log into anthem.com, go to "Pharmacy," and search for dapagliflozin or Farxiga. Note the tier, PA requirement, and any quantity limits.
2. Ask your physician to submit a PA on the correct indication. Ensure the ICD-10 code matches your primary diagnosis (diabetes, HF, or CKD).
3. Provide complete lab documentation. HbA1c, eGFR, UACR, and echocardiogram (if HF indication) should accompany the PA.
4. Apply for the AstraZeneca savings card at the same time. If commercially insured, do not wait for PA approval to register at farxiga.com.
5. Appeal promptly if denied. Federal rules require you file an internal appeal within 180 days of the denial date for most commercial plans.
6. Ask your physician for a peer-to-peer call with Anthem's medical director if the first-level appeal is denied.