Does Blue Cross Blue Shield of North Carolina Cover Farxiga?

What Is Farxiga and Why Does Coverage Complexity Matter?

Farxiga (dapagliflozin) is a sodium-glucose cotransporter-2 (SGLT2) inhibitor approved by the FDA for three distinct indications, which is a wider label than most drugs in its class. The FDA first approved dapagliflozin for type 2 diabetes in January 2014, then expanded the label to include heart failure with reduced ejection fraction (HFrEF) in May 2020, and subsequently added chronic kidney disease (CKD) in April 2021 and heart failure with preserved ejection fraction (HFpEF) in February 2022. [1]

Because Farxiga carries multiple indications, coverage determinations at BCBSNC vary depending on which diagnosis code appears on the prior authorization request. A request filed under ICD-10 E11.9 (type 2 diabetes without complications) triggers different clinical criteria than one filed under I50.20 (heart failure) or N18.3 (CKD stage 3).

Why No Generic Exists Yet

AstraZeneca's dapagliflozin patents run through 2027 in the United States, so no FDA-approved generic is commercially available as of mid-2025. [2] That patent status is one reason insurers place Farxiga on higher cost-sharing tiers: without a generic competitor to anchor the tier, the drug remains in the preferred or non-preferred brand category.

The Clinical Case Behind the Price

The DECLARE-TIMI 58 trial (N=17,160) showed dapagliflozin reduced the composite of cardiovascular death or worsening heart failure by 17% versus placebo (HR 0.83; 95% CI 0.73 to 0.95) in patients with type 2 diabetes. [3] DAPA-HF (N=4,744) demonstrated a 26% relative risk reduction in worsening heart failure or cardiovascular death (HR 0.74; 95% CI 0.65 to 0.85; P<0.001) among patients with HFrEF regardless of diabetes status. [4] DAPA-CKD (N=4,304) showed dapagliflozin reduced the composite of sustained 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). [5]

These trial results inform why the American Diabetes Association's 2025 Standards of Care recommend SGLT2 inhibitors for patients with type 2 diabetes and established cardiovascular disease, heart failure, or CKD independent of HbA1c. [6]

How BCBSNC Organizes Its Formulary

Tier Structure

BCBSNC commercial plans generally use a four- or five-tier formulary. Tier 1 is generics. Tier 2 is preferred generics or low-cost brands. Tier 3 is preferred brand-name drugs. Tier 4 is non-preferred brands. Tier 5, where present, is specialty drugs.

Farxiga most often lands at Tier 3 on BCBSNC commercial employer-sponsored plans and at Tier 3 or Tier 4 on ACA marketplace plans. The precise tier depends on the contract year and the specific plan variant your employer negotiated. Your Summary of Benefits and Coverage (SBC) document will name the tier, and the BCBSNC online drug lookup tool at bcbsnc.com confirms real-time placement.

What Tier Placement Means for Your Copay

At Tier 3, a typical BCBSNC commercial member pays a copay in the range of $50, $100 per 30-day fill before meeting the deductible, and the copay drops to roughly $40, $70 post-deductible. High-deductible health plans (HDHPs) require you to pay full cost until you meet the deductible, which for 2025 is set at a minimum of $1,650 for self-only coverage under IRS guidelines. [7]

These figures are estimates. Always verify your specific cost-sharing in your Explanation of Benefits (EOB) or by calling the BCBSNC member services number on the back of your insurance card.

Prior Authorization Requirements at BCBSNC

Standard Clinical Criteria

BCBSNC requires prior authorization (PA) for Farxiga on most plan types. The clinical criteria the PA team reviews typically include:

• A confirmed diagnosis matching one of Farxiga's FDA-approved indications
• For type 2 diabetes: documentation that metformin is contraindicated, not tolerated, or already being used at maximum tolerated dose
• For heart failure: confirmation of ejection fraction measurement and NYHA functional class
• For CKD: a documented eGFR value and urine albumin-to-creatinine ratio (UACR)
• Prescriber attestation that the clinical benefit outweighs risks specific to the patient

The American College of Cardiology and the American Heart Association's 2022 Heart Failure Guidelines give SGLT2 inhibitors a Class I, Level A recommendation for patients with HFrEF, which directly supports PA submissions for that indication. [8]

Step Therapy for Type 2 Diabetes

For the type 2 diabetes indication, BCBSNC commonly applies step therapy requiring a trial of metformin (usually 90 days at a therapeutic dose) before approving an SGLT2 inhibitor. Some plans also require a trial of a sulfonylurea or a DPP-4 inhibitor. If your physician documents clinical reasons why those agents are inappropriate (renal insufficiency, hypoglycemia risk, weight concerns), the step therapy requirement can be waived on the PA form.

North Carolina enacted a step therapy override law (G.S. 58-3-221) that requires insurers to grant a step therapy exception within 72 hours (or 24 hours for urgent cases) when a physician provides adequate clinical justification. [9] Your prescriber should reference this statute explicitly when submitting an override request.

How to Start the Prior Authorization Process

Your prescriber or their office staff initiates the PA through the BCBSNC provider portal or by fax. Supporting documents should include:

1. Relevant lab values (HbA1c, eGFR, UACR, echocardiogram report as applicable)
2. A medication history showing prior therapies tried
3. Clinical notes referencing ADA, ACC/AHA, or KDIGO guideline recommendations
4. The DECLARE-TIMI 58, DAPA-HF, or DAPA-CKD trial results if the indication is cardiovascular or renal

BCBSNC must render a PA decision within 3 business days for standard requests and 1 business day for urgent requests under North Carolina Insurance Regulation. [10]

BCBSNC Medicare Advantage and Farxiga

BCBSNC administers several Medicare Advantage (MA) plans in North Carolina. Farxiga's placement on MA formularies follows the Medicare Part D benefit structure, which the Centers for Medicare and Medicaid Services (CMS) oversees. [11]

Part D Tier Placement

On BCBSNC Medicare Advantage Part D formularies, Farxiga typically sits at Tier 3 (preferred brand) with a standard copay in the $40, $60 range during the initial coverage phase. During the coverage gap (formerly the "donut hole"), standard cost-sharing applies until the catastrophic coverage threshold is met.

For 2025, CMS redesigned the Part D benefit so that out-of-pocket drug costs are capped at $2,000 annually for Medicare beneficiaries. [12] This cap meaningfully limits the total annual exposure for patients on Farxiga who previously faced four-figure costs in the coverage gap.

Low-Income Subsidy (LIS) Considerations

Patients who qualify for the Part D Low-Income Subsidy (Extra Help) pay a substantially reduced copay, typically $4.50 for generic drugs and $11.20 for brand drugs at the lower LIS tier for 2025. Farxiga's brand status means it falls into the higher LIS copay bracket unless the plan has negotiated a preferred tier placement. [13]

BCBSNC Medicaid Managed Care and Farxiga

BCBSNC participates in North Carolina's Medicaid managed care program as Blue Cross NC Medicaid. North Carolina Medicaid's Preferred Drug List (PDL) determines coverage for outpatient drugs. As of 2025, dapagliflozin requires prior authorization on the NC Medicaid PDL, and the preferred SGLT2 inhibitor agents on that list may differ from those on commercial formularies. [14]

Patients on Medicaid should confirm coverage through the NC Medicaid PDL search tool maintained by the NC Division of Health Benefits.

What to Do If BCBSNC Denies Farxiga

File a Formal Appeal

A denial is not final. BCBSNC members have the right to a formal internal appeal within 180 days of a denial notice. The appeal should include:

• A letter from the prescribing physician explaining the medical necessity
• Copies of relevant trial data (DAPA-HF, DAPA-CKD, DECLARE-TIMI 58)
• Current guideline statements from the ADA, ACC/AHA, or KDIGO
• Any patient-specific factors that make alternative drugs less appropriate

Request an External Review

If the internal appeal is denied, North Carolina law entitles members to an independent external review by a state-certified Independent Review Organization (IRO). The NC Department of Insurance oversees this process. External reviews for SGLT2 inhibitors frequently succeed when strong clinical documentation accompanies the request.

AstraZeneca Patient Assistance

AstraZeneca offers two programs that can bridge coverage gaps. The AZ&ME Prescription Savings Program provides Farxiga at no cost to uninsured or underinsured patients who meet income criteria (generally household income at or below 400% of the federal poverty level). [15] The AstraZeneca Savings Card reduces the monthly copay to as low as $0 for eligible commercially insured patients with no income restriction, though Medicare and Medicaid patients are excluded.

How Farxiga's Three Indications Affect Your Specific PA

The table below summarizes how the indication on your PA request changes the clinical criteria BCBSNC reviewers apply. Prescribers should file the PA under the primary indication that most strongly matches the patient's chart, because mismatched ICD-10 codes are a leading cause of unnecessary denials.

| Indication | ICD-10 | Key Supporting Data to Include | Typical Step Therapy? | |---|---|---|---| | Type 2 Diabetes | E11.x | HbA1c, metformin trial documentation, ADA 2025 Standards | Yes | | Heart Failure (HFrEF) | I50.20, I50.23 | Echo EF <40%, NYHA class, DAPA-HF HR 0.74 | Less common | | Heart Failure (HFpEF) | I50.30, I50.33 | Echo EF >40%, EMPEROR-Preserved or DELIVER data | Less common | | Chronic Kidney Disease | N18.3, N18.5 | eGFR, UACR, DAPA-CKD HR 0.61, KDIGO 2022 | Less common |

For heart failure and CKD indications, step therapy requirements are less frequent because few older agents carry the same level-of-evidence support. The ACC/AHA 2022 Heart Failure Guidelines state: "In patients with HFrEF, SGLT2 inhibitors are recommended to reduce hospitalization for HF and cardiovascular mortality, irrespective of the presence or absence of type 2 diabetes (Class I, Level A)." [8]

For the CKD indication, the KDIGO 2022 Clinical Practice Guideline for Diabetes Management in CKD recommends dapagliflozin or another SGLT2 inhibitor for patients with type 2 diabetes and CKD with eGFR >20 mL/min/1.73 m2, regardless of HbA1c target. [16]

Comparing Farxiga to Other SGLT2 Inhibitors on BCBSNC Formularies

Two other SGLT2 inhibitors may sit at a lower tier on your specific BCBSNC plan, making them easier to access with less prior authorization friction.

Jardiance (empagliflozin) carries FDA approval for type 2 diabetes, heart failure (HFrEF and HFpEF), and CKD, and the EMPA-REG OUTCOME trial (N=7,020) showed a 38% relative risk reduction in cardiovascular death versus placebo (HR 0.62; 95% CI 0.49 to 0.77; P<0.001). [17] Invokana (canagliflozin) is approved for type 2 diabetes and CKD; the CREDENCE trial (N=4,401) demonstrated a 30% reduction in the primary composite renal outcome (HR 0.70; 95% CI 0.59 to 0.83; P=0.00001). [18]

If Farxiga is non-preferred on your plan and empagliflozin or canagliflozin is preferred, your physician may determine that switching to a preferred SGLT2 inhibitor is clinically appropriate, eliminating prior authorization entirely. That is a reasonable conversation to have at your next appointment.

Practical Steps to Get Farxiga Covered at BCBSNC

Step 1: Confirm Your Plan's Formulary Tier

Log into your BCBSNC member account at bcbsnc.com and use the formulary search. Enter "dapagliflozin" or "Farxiga." The search returns the tier, any PA requirements, and the quantity limit.

Step 2: Ask Your Prescriber to Submit a PA With Complete Documentation

Incomplete PA requests are the single largest cause of delays. Ask your physician's office to include lab values, a medication history, and a brief narrative citing the relevant clinical trial and guideline. Turnaround time drops significantly when the submission is complete at the first attempt.

Step 3: Apply the AstraZeneca Savings Card Immediately

Even while the PA is pending, if you have commercial insurance you can download the AstraZeneca Savings Card from astrazeneca-us.com and use it at your pharmacy for interim fills at reduced cost. The card is separate from the PA process and does not expire while the PA is under review. [15]

Step 4: Track the PA Timeline and Follow Up

BCBSNC must respond within 3 business days for standard PAs in North Carolina. [10] Call your physician's office on day 4 if no response has arrived. A second call to BCBSNC member services on the same day can help identify whether additional information is needed.

Step 5: Appeal in Writing With Trial Data If Denied

A denial letter from BCBSNC lists the specific clinical criteria not met. Address each criterion individually in the appeal letter. Citing DAPA-HF (HR 0.74; P<0.001) or DAPA-CKD (HR 0.61; P<0.001) by name and trial number strengthens the appeal substantially. [4][5]

Cost Reduction Strategies Beyond Insurance

Several programs reduce out-of-pocket costs for Farxiga even when coverage is in place.

AstraZeneca Savings Card. Commercially insured patients who meet eligibility criteria may pay $0 per month for up to 12 fills. Confirm eligibility at the AstraZeneca website because terms update annually.

GoodRx and Similar Discount Programs. GoodRx pricing for Farxiga 10 mg (30 tablets) ranges from approximately $500 to $620 depending on the pharmacy. These prices are below the retail list price but still higher than a covered copay on most commercial plans. Discount cards cannot be combined with insurance on the same fill.

340B Program Pharmacies. Patients who receive care at a federally qualified health center (FQHC) or a qualifying hospital may access Farxiga at significantly reduced 340B program pricing. Ask your care team whether your clinic participates in 340B. The Health Resources and Services Administration (HRSA) maintains a public database of covered entities. [19]

NeedyMeds Database. NeedyMeds.org aggregates patient assistance program eligibility tools, including AstraZeneca's AZ&ME program for uninsured and underinsured patients.

What HealthRX Clinicians Can Do for You

HealthRX clinicians routinely prepare prior authorization documentation for patients seeking Farxiga coverage through BCBSNC and other North Carolina insurers. A completed PA package from a HealthRX provider includes the relevant ICD-10 codes, supporting lab values, a medication history, and direct citations to DECLARE-TIMI 58, DAPA-HF, or DAPA-CKD as appropriate for your diagnosis. Patients who receive a structured PA submission generally experience shorter review timelines than those whose prescribers submit minimal documentation.

If your PA is denied, HealthRX clinicians can draft the appeal letter and coordinate the external review request. The North Carolina step therapy override statute (G.S. 58-3-221) allows your physician to request an exception within 72 hours, and HealthRX providers are familiar with that process. [9]