Does Blue Cross Blue Shield of Minnesota Cover Farxiga?

How BCBSMN Classifies Farxiga on Its Formulary

Blue Cross Blue Shield of Minnesota maintains separate formularies for its commercial, individual marketplace (MNsure), and Medicare Advantage product lines. Across most of these formularies, Farxiga appears as a preferred-brand medication, typically sitting on Tier 2 or Tier 3. That placement means the drug is covered but carries a higher cost-share than generic alternatives like metformin or glipizide.

BCBSMN updates its formulary quarterly. The specific tier can shift between plan years or even mid-year during formulary revisions, so checking the most recent Formulary Drug List on the BCBSMN member portal is always the most reliable step. SGLT2 inhibitors as a class have gained formulary preference over the past several years as cardiovascular and renal outcome data have accumulated. The DAPA-HF trial (N=4,744) demonstrated that dapagliflozin reduced the composite of worsening heart failure or cardiovascular death by 26% compared to placebo (hazard ratio 0.74, 95% CI 0.65 to 0.85) in patients with heart failure and reduced ejection fraction [1]. These results, along with the DAPA-CKD findings, have strengthened the case for formulary inclusion across major payers.

For Medicare Advantage members enrolled through BCBSMN, Farxiga falls under Part D prescription drug coverage. Part D plans often place SGLT2 inhibitors on Tier 3 (preferred brand) with a copay between $42 and $100, depending on the specific plan selected during open enrollment [2].

Prior Authorization Requirements

Most BCBSMN plans require prior authorization before dispensing Farxiga. This is standard practice among large insurers for branded SGLT2 inhibitors. The authorization criteria typically require documentation that the patient has a confirmed diagnosis of type 2 diabetes mellitus, heart failure, or chronic kidney disease, and that the prescriber can demonstrate at least one of the following: an inadequate response to metformin monotherapy (defined as HbA1c remaining above the individualized target after at least 90 days at maximally tolerated dose), a contraindication or intolerance to metformin (such as an eGFR below 30 mL/min/1.73 m², lactic acidosis history, or documented gastrointestinal intolerance), or an FDA-approved indication beyond glycemic control (heart failure or CKD).

The American Diabetes Association's 2024 Standards of Care recommend SGLT2 inhibitors as preferred second-line agents for patients with type 2 diabetes who have established atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease, independent of HbA1c level or metformin use [3]. Citing this guideline in your prior authorization submission strengthens the clinical rationale significantly.

Prior authorization requests submitted electronically through the CoverMyMeds platform or the BCBSMN provider portal are typically processed within 72 hours for standard requests. Urgent requests receive a 24-hour turnaround. If denied, you have the right to a formal appeal.

Step Therapy and How to Manage It

Step therapy (sometimes called "fail first") is the most common barrier BCBSMN members encounter when trying to fill a Farxiga prescription. Under step therapy protocols, the plan requires documented use of one or more lower-cost medications before approving a branded agent.

For Farxiga prescribed for type 2 diabetes, the typical step therapy sequence is: metformin first, then a sulfonylurea or DPP-4 inhibitor, then SGLT2 inhibitor approval. Some plans compress this to a single metformin step. The key detail is that "failure" does not always mean the prior drug was completely ineffective. Documented intolerance (persistent GI side effects with metformin, for example) or a clinical contraindication (eGFR <30, pregnancy, history of diabetic ketoacidosis with a sulfonylurea) can satisfy step therapy requirements.

For heart failure and CKD indications, step therapy requirements are often waived entirely. The DAPA-CKD trial (N=4,304) showed dapagliflozin reduced the risk of a sustained decline in eGFR of at least 50%, end-stage kidney disease, or death from renal or cardiovascular causes by 39% (HR 0.61, 95% CI 0.51 to 0.72, P<0.001) [4]. Because SGLT2 inhibitors carry an FDA indication for CKD independent of diabetes status, BCBSMN's clinical policies often recognize these as first-line agents for renal protection, bypassing the diabetes-specific step therapy ladder.

If you believe step therapy is clinically inappropriate for your situation, your prescriber can submit a step therapy exception request. Minnesota state law (Minn. Stat. § 62Q.83) requires health plans to grant exceptions when the required step drug is contraindicated, has caused an adverse reaction, or is expected to be ineffective based on the patient's clinical history.

What You Can Expect to Pay Out of Pocket

The retail price of Farxiga without insurance runs approximately $550 to $620 for a 30-day supply of 10 mg tablets. With BCBSMN coverage, your actual cost depends on your plan's tier structure, deductible status, and whether you have met your annual out-of-pocket maximum.

Commercial plan members on a copay-based design typically pay between $30 and $75 per fill for a Tier 2 preferred brand, or $75 to $150 for a Tier 3 non-preferred brand. Coinsurance-based plans (common in high-deductible health plans paired with an HSA) often charge 20% to 40% of the negotiated rate after the deductible is met, which could mean $80 to $200 per month until the out-of-pocket maximum is reached.

AstraZeneca offers a manufacturer copay assistance card for commercially insured patients. Eligible patients may pay as little as $0 per month, with a maximum annual benefit that typically caps around $1,800 to $2,400 per year [5]. This card cannot be used by patients enrolled in Medicare, Medicaid, or other federal healthcare programs. Medicare Part D members should instead check whether they qualify for the Extra Help (Low-Income Subsidy) program, which can reduce monthly copays to $0 to $11 per prescription [6].

A 2023 analysis published in Diabetes Care found that among commercially insured adults prescribed SGLT2 inhibitors, mean out-of-pocket spending was $47 per 30-day fill when manufacturer coupons were applied, compared to $112 without coupon use [7]. That difference affects adherence directly. The same study documented that patients with out-of-pocket costs exceeding $50 per month were 32% more likely to abandon their SGLT2 inhibitor prescription within the first six months.

Coverage for Farxiga's Non-Diabetes Indications

Farxiga holds three distinct FDA-approved indications: type 2 diabetes (approved 2014), heart failure with reduced or preserved ejection fraction (expanded 2020 and 2023), and chronic kidney disease at risk of progression (approved 2021) [8]. This matters for BCBSMN coverage because the prior authorization criteria and step therapy requirements differ by indication.

When Farxiga is prescribed for heart failure, BCBSMN's clinical policy typically aligns with the ACC/AHA/HFSA 2022 guideline, which gives SGLT2 inhibitors a Class I recommendation (Level of Evidence A) for patients with heart failure regardless of ejection fraction or diabetes status [9]. Coverage approval rates for heart failure indications tend to be higher than for diabetes-only indications because the cardiovascular benefit is well-established and there are fewer generic therapeutic alternatives in this space.

For CKD, the KDIGO 2024 clinical practice guideline recommends SGLT2 inhibitors for patients with CKD and an eGFR of 20 to 45 mL/min/1.73 m² (or 45 to 90 mL/min/1.73 m² with albuminuria), regardless of diabetes status [10]. Prescribers submitting prior authorization for CKD should reference these guidelines and include recent lab values (eGFR, urine albumin-to-creatinine ratio) to demonstrate eligibility.

Dr. Katherine Tuttle, executive director for research at Providence Health Care, has stated: "SGLT2 inhibitors represent one of the most significant advances in nephrology in decades. The renal protection they provide is independent of their glucose-lowering effect, and coverage policies need to reflect that clinical reality" [11].

How to Appeal a Farxiga Denial from BCBSMN

If BCBSMN denies your prior authorization or step therapy exception request, a structured appeal can overturn the decision. First-level appeals are reviewed by a physician who was not involved in the initial denial. You or your prescriber must submit the appeal within 60 days of the denial notice for commercial plans, or 60 calendar days for Medicare Advantage plans.

An effective appeal letter should include three elements: the specific clinical indication (diabetes, HF, or CKD), the clinical rationale referencing current guidelines (ADA Standards of Care, ACC/AHA heart failure guidelines, or KDIGO CKD guidelines), and documentation of why alternative therapies are inappropriate. If the patient has tried and failed metformin, include dates, doses, HbA1c values before and after, and the reason for discontinuation.

The Minnesota Department of Commerce oversees external review of health plan denials for fully insured commercial plans. If BCBSMN denies your internal appeal, you can request an independent external review through the state. Self-insured employer plans (ERISA plans) follow a different appeals pathway governed by federal law, but the documentation strategy remains the same.

According to a 2022 report from the Kaiser Family Foundation, approximately 59% of prior authorization denials that are appealed at the first level are eventually overturned across commercial insurers [12]. The rate is higher for medications with strong guideline support, like SGLT2 inhibitors.

Comparing Farxiga to Other Covered SGLT2 Inhibitors

BCBSMN formularies may also cover Jardiance (empagliflozin) and, in some plan years, Invokana (canagliflozin). Formulary preference between Farxiga and Jardiance can vary by plan. If one SGLT2 inhibitor is preferred over the other, your copay could differ by $20 to $60 per month.

From a clinical standpoint, dapagliflozin and empagliflozin have similar efficacy profiles for glucose lowering, cardiovascular protection, and renal outcomes. The EMPA-REG OUTCOME trial (N=7,020) demonstrated a 38% relative risk reduction in cardiovascular death with empagliflozin versus placebo in patients with type 2 diabetes and established cardiovascular disease [13]. The DECLARE-TIMI 58 trial (N=17,160) showed dapagliflozin reduced the rate of cardiovascular death or hospitalization for heart failure by 17% versus placebo (HR 0.83, 95% CI 0.73 to 0.95) in a broader population that included patients with multiple cardiovascular risk factors [14].

If BCBSMN prefers Jardiance over Farxiga on your specific plan, switching between the two is clinically straightforward. Both are dosed once daily, have similar side-effect profiles (genital mycotic infections, urinary tract infections, volume depletion), and carry the same class-level warnings. Your prescriber can document a therapeutic interchange if Farxiga is non-preferred and Jardiance is available at a lower tier.

Tips for Getting Farxiga Covered Faster

Work with your prescriber's office to submit prior authorization proactively, before you arrive at the pharmacy. Electronic prior authorization through CoverMyMeds or SureScripts reduces turnaround time to 24 to 48 hours in many cases. Include recent HbA1c values, eGFR, urine albumin-to-creatinine ratio, and ejection fraction (if applicable) with the initial submission.

Dr. Robert Gabbay, Chief Scientific and Medical Officer of the American Diabetes Association, has noted: "The evidence base for SGLT2 inhibitors now spans diabetes, heart failure, and kidney disease. These medications should be accessible to every patient who meets the clinical criteria, and the prior authorization process should reflect the strength of the evidence" [15].

If cost remains a barrier even with insurance, explore AstraZeneca's patient assistance program (AZ&Me), which provides Farxiga at no cost to qualifying patients with household incomes at or below 400% of the federal poverty level. For a single-person household in 2026, that threshold is approximately $62,400 annually. Applications can be submitted through the AZ&Me website or by calling AstraZeneca's patient services line.

BCBSMN members enrolled through MNsure marketplace plans should also check whether their plan qualifies for cost-sharing reductions (CSR), which lower copays and deductibles for households earning 100% to 250% of the federal poverty level. CSR-eligible Silver plans can reduce a Tier 3 brand copay from $75 to as low as $15 per fill.