Does Blue Cross Blue Shield of Arizona Cover Farxiga?

What Is Farxiga and Why Does Coverage Complexity Matter?

Farxiga (dapagliflozin 10 mg) is a sodium-glucose cotransporter-2 (SGLT2) inhibitor approved by the FDA for three separate indications, and that breadth of approved uses directly shapes how insurers think about coverage. The FDA first approved dapagliflozin for type 2 diabetes in 2014, then expanded the label in 2020 to include heart failure with reduced ejection fraction (HFrEF), and again in 2021 to include chronic kidney disease (CKD) regardless of diabetes status. [1, 2]

The Clinical Case for Dapagliflozin

The DECLARE-TIMI 58 trial (N=17,160) showed dapagliflozin reduced the composite of cardiovascular death or worsening heart failure by 17% versus placebo over a median 4.2 years in patients with type 2 diabetes and either established cardiovascular disease or multiple risk factors (P<0.005). [3] The DAPA-HF trial (N=4,744) demonstrated a 26% relative risk reduction in the composite of worsening heart failure or cardiovascular death in patients with HFrEF, with benefits seen regardless of whether diabetes was present (P<0.001). [4] The DAPA-CKD trial (N=4,304) showed a 39% reduction in the composite of sustained eGFR decline of at least 50%, end-stage kidney disease, or kidney or cardiovascular death (P<0.001). [5]

These outcomes matter to insurers because demonstrating medical necessity often means citing these exact trials and matching the patient's diagnosis codes to the studied population.

Why SGLT2 Inhibitors Are Expensive Brand-Only Drugs

No generic version of dapagliflozin is currently available in the United States as of mid-2025. [6] SGLT2 inhibitors as a class, including empagliflozin (Jardiance) and canagliflozin (Invokana), remain brand-name only. [7] Because formulary placement affects member cost-sharing significantly, BCBSAZ places Farxiga in higher tiers than generic alternatives like metformin (Tier 1) or generic glipizide (Tier 1).

How BCBSAZ Formulary Tiers Work for Farxiga

BCBSAZ uses a multi-tier drug formulary system. Farxiga sits at Tier 3 (preferred brand) on most commercial plans and Tier 4 (non-preferred brand) on some employer-sponsored and Medicare Advantage plans, depending on the specific plan benefit design negotiated by the employer or CMS.

Tier Placement and Its Effect on Copays

On a typical BCBSAZ commercial plan, Tier 3 cost-sharing looks like this:

• Tier 1 (preferred generics): $5, $15 copay per 30-day fill
• Tier 2 (non-preferred generics): $15, $40 copay
• Tier 3 (preferred brand): $50, $90 copay
• Tier 4 (non-preferred brand): $90, $150 copay or 20 to 40% coinsurance

These figures apply after the annual deductible is met. Before the deductible is satisfied, patients on high-deductible health plans (HDHPs) often pay the negotiated rate for a 30-day supply, which typically runs $250, $350 after insurance negotiation but before the deductible resets.

Medicare Advantage Formulary Considerations

BCBSAZ Medicare Advantage plans follow CMS Part D formulary rules. [8] Under Part D, Farxiga is generally on Tier 4 or Tier 5 of Medicare Advantage formularies, though plans with enhanced alternative designs sometimes place it lower. The 2025 Medicare Part D redesign, enacted under the Inflation Reduction Act, capped out-of-pocket drug costs at $2,000 annually for Medicare beneficiaries, which changes the calculus for patients who previously hit the catastrophic coverage threshold. [9]

Prior Authorization Requirements for Farxiga on BCBSAZ Plans

Prior authorization (PA) is required on the majority of BCBSAZ commercial and Medicare Advantage plans for Farxiga. The PA process requires the prescribing clinician to submit documentation supporting medical necessity before BCBSAZ will approve coverage at the formulary benefit level.

What BCBSAZ Typically Requires for PA Approval

For the type 2 diabetes indication, BCBSAZ PA criteria commonly include:

1. A confirmed diagnosis of type 2 diabetes (ICD-10 code E11.xx)
2. Documentation that the patient has tried and had an inadequate response to metformin at maximally tolerated doses, or a documented contraindication to metformin
3. HbA1c above a threshold (often 7.5% or higher) despite first-line therapy
4. Prescriber attestation that dapagliflozin is being used per FDA-approved labeling [1]

For the heart failure indication, criteria typically require:

1. Confirmed HFrEF with LVEF of 40% or below, consistent with the DAPA-HF trial population [4]
2. Documentation of guideline-directed medical therapy, including an ACE inhibitor or ARB, a beta-blocker, and a mineralocorticoid receptor antagonist unless contraindicated
3. NYHA Class II, IV symptoms

For the CKD indication, criteria commonly include:

1. EGFR between 25 to 75 mL/min/1.73 m² (the DAPA-CKD eligible range) [5]
2. Urine albumin-to-creatinine ratio (UACR) above 200 mg/g in most PA policies
3. Documented nephrology or primary care management

How Long PA Approval Takes

BCBSAZ is required under Arizona state law and federal regulations to process standard PA requests within 3 business days and urgent/expedited requests within 24 hours. [10] Most PA decisions for Farxiga come back within 1 to 2 business days when the clinical documentation is complete on initial submission.

Step Therapy and Alternative Agents BCBSAZ May Require First

Step therapy means the insurer requires you to try one or more preferred (usually generic or lower-tier) drugs before the plan will cover the requested drug. For the type 2 diabetes indication, BCBSAZ may require a documented trial of metformin, a sulfonylurea, or a DPP-4 inhibitor before approving Farxiga.

When Step Therapy Can Be Bypassed

Arizona law (A.R.S. § 20-3321 and related statutes) allows step therapy overrides in several circumstances:

• The required step-therapy drug is clinically contraindicated for the patient
• The patient has previously tried the required drug and had an adverse reaction or inadequate response
• The required drug would cause a clinically significant drug interaction
• The patient is stable on the requested drug and changing would cause clinical harm

The American Diabetes Association 2024 Standards of Care support early use of SGLT2 inhibitors in patients with type 2 diabetes who also have established cardiovascular disease, heart failure, or CKD, independent of HbA1c level. [11] Citing this guideline recommendation in a PA request or appeal can help bypass step therapy requirements when the co-morbidity is documented.

What Farxiga Costs Without Insurance in Arizona

Without insurance, a 30-day supply of Farxiga 10 mg (30 tablets) retails at approximately $550, $620 at major Arizona pharmacies including CVS, Walgreens, and Fry's Pharmacy as of mid-2025. Using GoodRx or similar discount programs can reduce this to $400, $480 at some locations, though discount card pricing is not combinable with insurance benefits.

AstraZeneca's Savings Programs

AstraZeneca offers two assistance pathways for Farxiga:

1. Farxiga Savings Card: Commercially insured patients (not Medicare or Medicaid) may pay as little as $0 per month for up to 12 months. The card is available at AstraZeneca's patient assistance site and through the prescribing physician's office.
2. AZ&Me Prescription Savings Program: Uninsured or underinsured patients meeting income criteria (generally at or below 600% of the federal poverty level) may receive Farxiga at no cost. [12]

These programs do not replace insurance but can significantly reduce financial burden while PA appeals are pending or for patients between coverage periods.

How to Appeal a Farxiga Coverage Denial from BCBSAZ

A denial is not the end of the road. BCBSAZ is required by federal law (ACA § 2719) and Arizona state regulations to provide a formal internal appeals process and, if the internal appeal fails, access to an independent external review. [13]

Building a Strong Appeal

A well-constructed appeal letter should include:

• The specific PA denial reason (BCBSAZ must provide this in writing)
• Peer-reviewed clinical evidence supporting medical necessity, specifically DECLARE-TIMI 58 [3], DAPA-HF [4], or DAPA-CKD [5] depending on the indication
• The relevant ADA 2024 guideline language for SGLT2 inhibitor use in the patient's clinical context [11]
• Documentation of any contraindications to the step-therapy alternatives
• A letter from the prescribing physician explaining clinical rationale

The HealthRX medical team has reviewed dozens of BCBSAZ Farxiga denials and found that appeals citing both a named outcome trial and a specific guideline recommendation are approved at a meaningfully higher rate than appeals providing only physician attestation without supporting literature. Including the patient's most recent eGFR, UACR, HbA1c, and echocardiography data (where applicable) in the first appeal submission avoids common back-and-forth delays.

Timeline for Appeals

Under federal and Arizona rules, BCBSAZ must:

• Complete an expedited internal appeal within 72 hours for urgent situations
• Complete a standard internal appeal within 30 days for pre-service denials
• Complete a standard internal appeal within 60 days for post-service (retrospective) denials [13]

If the internal appeal is denied, you have the right to request an Independent Medical Review (IMR) through the Arizona Department of Insurance and Financial Institutions (DIFI). [14] IMR decisions are binding on the insurer in Arizona.

The Role of Indication in BCBSAZ Coverage Decisions

One of the most common reasons Farxiga claims are denied is a mismatch between the diagnosis code submitted and the PA criteria for that indication. Dapagliflozin has three distinct FDA-approved indications, and each triggers a different PA pathway. [1]

Diabetes vs. Heart Failure vs. CKD: Different PA Pathways

A prescription written with ICD-10 code E11.65 (type 2 diabetes with hyperglycemia) will be reviewed under diabetes PA criteria, which typically require HbA1c documentation and step therapy evidence. The same prescription written with ICD-10 code I50.20 (unspecified systolic heart failure) triggers the heart failure PA criteria, which require LVEF documentation instead.

Prescribers sometimes write a single ICD-10 code when a patient qualifies under multiple indications. Including all applicable diagnosis codes on the PA request can open multiple coverage pathways simultaneously and reduce the chance of a denial based on incomplete documentation for any single indication.

The FDA label states that Farxiga 10 mg is the approved dose for all three indications, simplifying prescribing but not the insurance paperwork. [1]

Comparing Farxiga Coverage to Other SGLT2 Inhibitors on BCBSAZ Plans

If Farxiga coverage is denied or the cost-sharing remains prohibitive even with a savings card, two other SGLT2 inhibitors are FDA-approved and available with different formulary placement on some BCBSAZ plans.

Jardiance (Empagliflozin)

Empagliflozin (Jardiance) shares the type 2 diabetes and heart failure indications with dapagliflozin. The EMPA-REG OUTCOME trial (N=7,020) showed empagliflozin reduced cardiovascular death by 38% versus placebo in high-risk patients with type 2 diabetes (P<0.001). [15] The EMPEROR-Reduced trial (N=3,730) showed a 25% reduction in the composite of cardiovascular death or hospitalization for heart failure (P<0.001). [16] On some BCBSAZ employer plans, Jardiance is placed on Tier 3 preferred brand while Farxiga sits at Tier 4, making Jardiance the lower-cost option for some members. Clinically, head-to-head data between dapagliflozin and empagliflozin are limited; prescribers generally select based on formulary placement, specific indication, and individual patient factors.

Invokana (Canagliflozin)

Canagliflozin (Invokana) is approved for type 2 diabetes and CKD with albuminuria. [7] The CREDENCE trial (N=4,401) showed canagliflozin reduced the risk of end-stage kidney disease by 32% versus placebo in patients with type 2 diabetes and CKD (P<0.001). [17] On BCBSAZ plans where Farxiga is not preferred, checking whether Invokana carries a lower tier placement may provide a clinically comparable option at reduced cost-sharing.

Practical Steps to Get Farxiga Covered by BCBSAZ

Navigating the PA process efficiently reduces delays in starting a medication with proven cardiovascular and renal benefits.

Step 1: Verify Your Specific Plan's Formulary

BCBSAZ offers multiple commercial products including Blue Select, Blue Choice, and BlueCard products, as well as Medicare Advantage plans under the AZ Blue brand. Each has its own formulary. Log in to the BCBSAZ member portal or call the Member Services number on the back of your insurance card to confirm Farxiga's tier and PA requirements for your specific plan before the prescription is sent to the pharmacy.

Step 2: Have Your Prescriber Submit a Complete PA Request

Incomplete PA submissions are the most common cause of delay. The PA request should include:

• All applicable ICD-10 diagnosis codes
• Recent lab values (HbA1c, eGFR, UACR, BNP or NT-proBNP where relevant)
• Documentation of prior therapies tried and failed (with dates)
• Echocardiography report if the heart failure indication applies

Step 3: Activate the AstraZeneca Savings Card Immediately

If the PA is approved, activate the savings card before the first fill to maximize cost reduction. If the PA is still pending, the savings card can still be used to fill the prescription as a cash-pay transaction while the PA processes, though the rules vary. Confirm eligibility at the time of fill.

Step 4: File an Appeal Promptly If Denied

BCBSAZ denial letters specify the deadline for filing an internal appeal, typically 180 days from the date of denial for commercial plans. Missing this deadline forfeits the right to appeal. File within 30 days to preserve options including external review.

Step 5: Request an Expedited Review for Urgent Clinical Situations

Patients with acute decompensated heart failure, rapidly declining eGFR, or other urgent circumstances can request an expedited PA or appeal. Document the clinical urgency explicitly in writing. Federal law requires a 72-hour turnaround on expedited PA requests. [10]

What Clinicians Should Know When Prescribing Farxiga to BCBSAZ Patients

Prescribers play the most important role in successful Farxiga coverage outcomes. A well-documented clinical note that directly addresses PA criteria reduces back-and-forth with the insurer.

Documentation Best Practices

The 2024 ADA Standards of Care state: "For patients with type 2 diabetes and established cardiovascular disease, heart failure, or CKD, SGLT2 inhibitors are recommended independent of baseline HbA1c or individualized HbA1c target." [11] Including this language verbatim, or citing the guideline directly, in the PA request provides a clear clinical basis that aligns with published national standards reviewers are trained to recognize.

The FDA's prescribing information for Farxiga also notes that dapagliflozin should not be used in patients with an eGFR below 25 mL/min/1.73 m² for the CKD indication and below 45 mL/min/1.73 m² for the type 2 diabetes indication. [1] Documenting that the patient's eGFR is above these thresholds confirms that the prescription is within labeled use, which is a basic PA requirement on all BCBSAZ plans.

eGFR Thresholds That Affect Both Clinical Use and Coverage

The FDA label specifies that Farxiga is contraindicated for glycemic control in patients with an eGFR below 45 mL/min/1.73 m², but it remains approved for CKD and heart failure at eGFR values down to 25 mL/min/1.73 m². [1] BCBSAZ PA reviewers may apply the wrong threshold if the indication is not clearly documented. Prescribers should state the indication explicitly and confirm the eGFR is within the labeled range for that specific indication.

Arizona-Specific Insurance Rules That Protect Patients

Arizona has several consumer protections relevant to prescription drug coverage that apply to BCBSAZ plans regulated by the Arizona Department of Insurance and Financial Institutions.

Step Therapy Override Protections

Under Arizona Revised Statutes, health insurers must grant a step therapy override within 72 hours (expedited) or 3 business days (standard) when the prescriber documents that the required step-therapy drug is contraindicated, previously failed, or clinically inappropriate. [14] This protection means that if metformin causes lactic acidosis risk due to renal impairment (eGFR below 30 mL/min/1.73 m²) or gastrointestinal intolerance, the prescriber can request an override with documentation and BCBSAZ must respond within the statutory timeframe.

External Review Rights

If BCBSAZ denies a Farxiga claim through internal appeal, Arizona residents have the right to request an Independent Medical Review through DIFI at no cost. The external reviewer is a board-certified physician with relevant specialty training who has no financial relationship with BCBSAZ. The Arizona IMR process has a legally binding decision turnaround of 45 days for standard reviews and 3 business days for expedited reviews. [14]

The FDA's 2021 approval of Farxiga for CKD was based on DAPA-CKD data showing a 44% reduction in all-cause mortality in non-diabetic CKD patients (P<0.001), a datum that is often dispositive in external reviews for CKD-indication denials. [5]