Does Amerigroup Cover Farxiga?

What Is Farxiga and Why Does the Covered Indication Matter?

Farxiga is FDA-approved for three separate conditions, and Amerigroup evaluates coverage criteria differently for each one. Getting the right diagnosis code on the prior-authorization request is the single fastest way to avoid a denial.

Dapagliflozin received its first FDA approval in January 2014 for glycemic control in adults with type 2 diabetes [1]. In May 2020, the FDA expanded the label to include reducing cardiovascular death or hospitalization for heart failure in adults with HFrEF, regardless of whether they have diabetes [2]. The third approval came in April 2021, when the FDA cleared dapagliflozin 10 mg to reduce the risk of sustained eGFR decline, end-stage kidney disease, cardiovascular death, and hospitalization for heart failure in adults with CKD at risk of progression [3].

Each indication rests on a separate landmark trial. 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) showed a 39% reduction in the primary composite kidney endpoint (hazard ratio 0.61; 95% CI 0.51 to 0.72; P<0.001) [5]. These outcomes data matter to Amerigroup's medical directors when reviewing PA requests, because plans are more likely to approve a drug with outcome-level evidence.

The 2023 American Diabetes Association Standards of Care state that SGLT2 inhibitors with proven cardiovascular benefit are recommended for patients with type 2 diabetes and established atherosclerotic cardiovascular disease, heart failure, or CKD regardless of HbA1c [6]. Citing this guideline language directly in a PA request can strengthen the case for coverage.

How Amerigroup Formularies Are Organized

Amerigroup operates Medicaid managed care and Medicare Advantage plans across roughly 20 states, and each state files its own formulary with the relevant state Medicaid agency or CMS. There is no single national Amerigroup formulary.

Most Amerigroup state formularies place brand-name SGLT2 inhibitors on Tier 3 (preferred brand) or Tier 4 (non-preferred brand). Tier placement determines your cost-sharing. On a typical Amerigroup Medicaid plan, Tier 3 drugs carry a copay of $3 to $8 per fill for members above the nominal Medicaid cost-sharing threshold; on Medicare Advantage plans, Tier 4 cost-sharing can reach 25% to 40% coinsurance during the initial coverage phase. Because Medicaid programs generally cap out-of-pocket costs at very low amounts for qualifying members, the financial burden is usually lower on Medicaid than on commercial insurance.

To find Farxiga's exact tier in your plan, use the drug lookup tool on Amerigroup's member portal at amerigroup.com, enter the plan name shown on your insurance card, and search for "dapagliflozin" or "Farxiga." The formulary document itself is publicly filed; you can also call the pharmacy benefits number on the back of your card.

The FDA's drug labeling resource for dapagliflozin can help you confirm the exact approved indication language to match against formulary criteria [7].

Prior Authorization Requirements for Farxiga

Prior authorization is the main barrier most Amerigroup members face. Approval criteria differ by indication, but the general framework is consistent across state plans.

For the type 2 diabetes indication, Amerigroup typically requires: a confirmed T2D diagnosis with documentation of HbA1c (usually above 7.0% or 7.5%), evidence that the member has tried metformin at an adequate dose for at least 90 days (step therapy), and a prescriber attestation that the medication is medically necessary. Some plans also require documentation of an eGFR above 25 mL/min/1.73 m² because the FDA label notes that the glucose-lowering effect is reduced at lower eGFR levels [1].

For the heart failure indication, PA criteria generally require a documented diagnosis of HFrEF with ejection fraction at or below 40%, usually verified by echocardiogram report, and evidence that guideline-directed medical therapy (beta-blocker, ACE inhibitor or ARN inhibitor, and mineralocorticoid antagonist) has been initiated or is contraindicated.

For CKD, plans typically require: eGFR 25 to 75 mL/min/1.73 m² (mirroring DAPA-CKD enrollment criteria) [5], confirmed albuminuria (urine albumin-to-creatinine ratio above 200 mg/g), and specialist involvement from a nephrologist or endocrinologist.

The PA form itself is submitted by your prescribing physician's office, not by you. Asking your doctor's office to attach the relevant trial references (DAPA-HF, DAPA-CKD) or the ADA guideline page can reduce back-and-forth with the plan's utilization management team.

Step Therapy and How to Challenge It

Step therapy means the plan requires you to try a cheaper drug first and document that it failed or caused intolerance before approving Farxiga. For the T2D indication, Amerigroup Medicaid plans in most states require a metformin trial. Some plans also require a trial of a sulfonylurea. This can delay access by 30 to 90 days if the prescriber does not already have documentation of prior therapy on file.

Step therapy requirements can often be bypassed when there is a clinical contraindication. Metformin is contraindicated at eGFR below 30 mL/min/1.73 m² per the FDA label [8], and sulfonylureas carry a meaningful hypoglycemia risk in elderly patients or those with renal impairment. If either applies, your doctor can document the contraindication and request a step-therapy exception, which most plans are legally required to process within 72 hours for non-urgent cases or 24 hours for urgent cases under CMS rules.

Federal regulations under the 21st Century Cures Act and CMS guidance require Medicare Advantage plans to grant step-therapy exceptions when the required drug is contraindicated, likely to cause an adverse reaction, or when the member has already tried and failed the required drug. Medicaid plans face similar requirements under state managed care contracts [9].

What Happens If Amerigroup Denies Farxiga Coverage

A denial is not the end of the road. Medicaid members have federal rights to appeal any adverse benefit determination. The standard appeal timeline is 30 days for standard reviews and 72 hours for expedited (urgent) reviews under 42 CFR Part 438 [9].

The appeal process typically involves three levels: internal appeal to Amerigroup's medical director, external independent review, and state fair hearing. Your physician's office should submit a letter of medical necessity with the appeal, referencing the specific FDA-approved indication, the clinical trial data (DAPA-HF or DAPA-CKD as appropriate), and any applicable ADA or ACC/AHA guideline language. The 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure gives SGLT2 inhibitors a Class I recommendation for HFrEF, meaning the guideline considers use strongly supported by evidence [10]. Citing a Class I recommendation in an appeal letter carries considerable weight.

If the internal appeal fails, request an external independent medical review. Studies have shown that external appeals overturn plan denials at rates between 30% and 50% for specialty medications, though exact figures vary by state and drug class.

Cost Without Coverage and Manufacturer Assistance Programs

Without insurance, Farxiga's list price runs approximately $590 to $620 for a 30-count supply of 10 mg tablets as of early 2025. That is a meaningful monthly expense for most patients.

AstraZeneca operates the AZ&Me Prescription Savings Program for patients who are uninsured or underinsured. Eligible patients with household income at or below 600% of the federal poverty level may receive Farxiga at no cost [11]. The application is available directly through AstraZeneca and requires income documentation.

For commercially insured patients who do not qualify for Medicaid, AstraZeneca's copay savings card can reduce out-of-pocket costs to as little as $0 per month (subject to eligibility and program terms). Note that this card cannot be used by patients enrolled in any federal or state government program, including Medicaid or Medicare, because of federal anti-kickback rules.

GoodRx and similar discount programs sometimes offer dapagliflozin at prices below the list price at participating pharmacies, though these prices fluctuate by pharmacy and location. GoodRx prices are not insurance and do not count toward your deductible.

Clinical Evidence Supporting Farxiga Coverage Requests

When Amerigroup's utilization management team evaluates a PA, they weigh clinical evidence against cost. Knowing the evidence helps your doctor frame the request effectively.

DECLARE-TIMI 58 (N=17,160) evaluated dapagliflozin in patients with type 2 diabetes and either established cardiovascular disease or multiple cardiovascular risk factors. Over a median 4.2-year follow-up, dapagliflozin significantly reduced hospitalization for heart failure by 27% (hazard ratio 0.73; 95% CI 0.61 to 0.88; P<0.001) [12]. This trial was specifically powered to evaluate cardiovascular safety and efficacy, and the heart failure reduction result is cited in the current FDA label [1].

DAPA-HF (N=4,744) showed the drug's benefit in HFrEF extended to patients without diabetes. At 16 months median follow-up, 16.3% of patients in the dapagliflozin group experienced a primary endpoint event versus 21.2% in the placebo group [4]. The number needed to treat was approximately 21 to prevent one primary endpoint event.

DAPA-CKD (N=4,304) was stopped early by the independent data monitoring committee because of the magnitude of benefit. At a median of 2.4 years, the primary composite endpoint occurred in 9.2% of the dapagliflozin group versus 14.5% of the placebo group [5]. These results formed the basis of the FDA's 2021 CKD approval [3].

The FDA's approval history and full prescribing information for dapagliflozin provide the regulatory basis that PA reviewers use as their starting framework [7].

Safety Considerations That May Affect Coverage Approval

Amerigroup's clinical criteria also screen for contraindications. Farxiga is contraindicated in patients with eGFR below 25 mL/min/1.73 m² for the CKD indication and below 30 mL/min/1.73 m² for the diabetes indication per the current label [7].

The drug carries FDA boxed warnings and label warnings for diabetic ketoacidosis (DKA), Fournier's gangrene, and genital mycotic infections. For the DKA risk, the FDA issued a safety communication in 2015 identifying SGLT2 inhibitors as a class as a potential DKA trigger, particularly in patients with type 1 diabetes or those who are insulin-deficient [13]. Amerigroup may flag a history of recurrent DKA as a concern during PA review, though this does not automatically result in denial for appropriately selected patients.

Urinary tract infections occur more commonly with SGLT2 inhibitors than with placebo. In DECLARE-TIMI 58, the rate of serious UTIs was 0.6% with dapagliflozin versus 0.5% with placebo, a difference that did not reach statistical significance [12]. Documenting a patient's clean UTI history can preemptively address this concern in the PA form.

How to Appeal a Farxiga Denial Step by Step

A denial letter from Amerigroup will specify the reason for denial, the appeals deadline, and the contact information for the appeals department. The standard internal appeal deadline is 60 days from the date of denial for Medicaid members under 42 CFR Part 438.402 [9].

Step 1: Ask your doctor's office to prepare a letter of medical necessity within 5 business days of receiving the denial. The letter should include the exact ICD-10 diagnosis code, relevant lab values (HbA1c, eGFR, UACR), prior medications tried and outcomes, and a direct reference to the applicable FDA label indication.

Step 2: Attach supporting documentation. Relevant documents include the echocardiogram report for HFrEF, nephrology notes for CKD, and the ADA or ACC/AHA guideline page with the Class I recommendation highlighted.

Step 3: Submit the appeal in writing and request confirmation of receipt. Keep a copy of every document submitted.

Step 4: If Amerigroup upholds the denial at the internal appeal stage, request an independent external review. Your denial letter must by law include instructions for requesting external review.

Step 5: If external review fails, request a state Medicaid fair hearing. This is a formal administrative proceeding at the state level and is your strongest avenue for reversal. Legal aid organizations in most states provide free assistance for Medicaid fair hearings related to medication denials.

Alternatives If Farxiga Remains Uncovered

If Amerigroup ultimately does not cover Farxiga after appeals, three clinical alternatives deserve consideration.

Empagliflozin (Jardiance) is another SGLT2 inhibitor with FDA approvals for type 2 diabetes, heart failure (both HFrEF and HFpEF), and CKD risk reduction. The EMPEROR-Reduced trial (N=3,730) showed empagliflozin reduced the primary composite of cardiovascular death or heart failure hospitalization by 25% (hazard ratio 0.75; 95% CI 0.65 to 0.86; P<0.001) [14]. Empagliflozin may be on a more favorable formulary tier on your specific Amerigroup plan.

Canagliflozin (Invokana) has FDA approval for type 2 diabetes and reducing cardiovascular events in patients with T2D and established CV disease, supported by the CANVAS trial (N=10,142) showing a 14% reduction in the primary MACE composite [15]. Canagliflozin also received an FDA indication for reducing end-stage kidney disease and CV death in patients with T2D and diabetic nephropathy, based on the CREDENCE trial.

If no SGLT2 inhibitor is covered without excessive cost-sharing, GLP-1 receptor agonists such as semaglutide (Ozempic) carry their own cardiovascular outcome data from SUSTAIN-6 and LEADER trials and may be more favorably tiered on some Amerigroup formularies.

Your prescriber and Amerigroup's pharmacy team can run a formulary exception request for an alternative if clinical necessity is documented.