Does Blue Cross Blue Shield of Texas Cover Farxiga?

What Is Farxiga and Why Does Coverage Matter?

Farxiga (dapagliflozin 5 mg and 10 mg tablets) is an oral SGLT2 inhibitor manufactured by AstraZeneca. The FDA first approved it in January 2014 for type 2 diabetes, then expanded the label in May 2020 for heart failure with reduced ejection fraction (HFrEF), and again in April 2021 for chronic kidney disease (CKD) regardless of whether diabetes is present [1][2]. Those three separate indications mean a single drug can appear on a formulary under different benefit categories depending on how your physician codes the prescription.

SGLT2 inhibitors as a class lower blood glucose by blocking glucose reabsorption in the kidneys, causing the body to excrete roughly 60, 80 grams of glucose per day in urine [3]. Beyond glycemic control, the DECLARE-TIMI 58 trial (N=17,160 patients with type 2 diabetes) demonstrated that dapagliflozin reduced the composite of cardiovascular death or worsening heart failure by 17% compared with placebo over a median 4.2-year follow-up [4]. The DAPA-HF trial (N=4,744) showed a 26% reduction in worsening heart failure or cardiovascular death in patients with HFrEF, many of whom did not have diabetes [5]. Results of that scale shaped AHA/ACC guideline language and pushed payers, including BCBSTX, to place Farxiga on formularies rather than exclude it outright.

Because the drug's retail list price runs approximately $600 per 30-day supply, insurance coverage is not an abstract concern. A Tier 3 copay on a typical BCBSTX commercial plan sits between $50 and $120 per fill after deductible, but out-of-pocket costs can spike dramatically if a plan classifies the drug as non-preferred or if a deductible has not yet been met.

How BCBSTX Organizes Its Drug Formulary

BCBSTX uses a tiered formulary structure that aligns with its parent company, Health Care Service Corporation (HCSC). Most commercial group plans use a 4-tier or 5-tier system:

• Tier 1: Generic drugs, lowest copay (often $0, $15)
• Tier 2: Preferred generic or lower-cost brands ($20, $45)
• Tier 3: Preferred brand-name drugs ($50, $120)
• Tier 4: Non-preferred brands ($90, $200)
• Tier 5 (specialty, where applicable): High-cost biologics and specialty drugs (coinsurance 20%, 33%)

Farxiga appears as a Tier 3 preferred brand on the majority of BCBSTX commercial formularies reviewed for 2024 to 2025, placing its standard copay well below the non-preferred tier. Individual and family plans purchased through the Texas marketplace (healthcare.gov) or through a small-group employer may use different tier assignments, so a blanket statement does not apply to every member.

The formulary document BCBSTX publishes is called the "Prescription Drug List" (PDL). Members can search it at the BCBSTX member portal (bcbstx.com) by entering the drug name and their plan type. The National Drug Code (NDC) for dapagliflozin 10 mg is the version most commonly prescribed for both diabetes and heart failure; confirm that exact NDC is listed, because different strengths sometimes fall on different tiers.

Prior Authorization: When Is It Required?

Prior authorization (PA) is required for Farxiga on a significant subset of BCBSTX commercial, Medicare Advantage, and marketplace plans. PA requirements differ by indication:

Type 2 diabetes: Some plans require documentation that the patient has an A1C above a specified threshold (commonly 7.5% or higher) and has already tried metformin for at least 90 days unless contraindicated. The 2024 ADA Standards of Care state that SGLT2 inhibitors are preferred add-on agents for patients with type 2 diabetes and established cardiovascular disease, CKD, or heart failure, which can support PA approval [6].

Heart failure (HFrEF): PA criteria typically require documentation of a left ventricular ejection fraction (LVEF) at or below 40%, a current cardiology or internal medicine diagnosis, and confirmation that the patient is on a guideline-directed background regimen (ACE inhibitor or ARB plus beta-blocker). The 2022 AHA/ACC/HFSA Heart Failure Guidelines gave SGLT2 inhibitors a Class I recommendation for patients with HFrEF [7].

Chronic kidney disease: Plans covering Farxiga for CKD frequently require an eGFR value (most commonly eGFR 25 to 75 mL/min/1.73m² per the DAPA-CKD trial inclusion criteria) and a urine albumin-to-creatinine ratio (UACR) above 200 mg/g in diabetic or non-diabetic CKD [8].

Your prescribing physician initiates the PA request through BCBSTX's electronic prior authorization portal or by fax. The insurer must respond within 72 hours for non-urgent requests under Texas Insurance Code standards. Urgent cases require a response within 24 hours.

The HealthRX PA Documentation Checklist for Farxiga at BCBSTX:

1. Most recent A1C result (within 3 months) for diabetes indication
2. Current medication list confirming prior metformin use or documented contraindication
3. LVEF report or echocardiogram result for HFrEF indication
4. Most recent eGFR and UACR lab values for CKD indication
5. ICD-10 diagnosis code matching the requested indication (E11.x for T2D, I50.20, I50.43 for HFrEF, N18.x for CKD)
6. Letter of medical necessity from the prescriber citing trial data (DECLARE-TIMI 58, DAPA-HF, or DAPA-CKD) and relevant guideline recommendations

Providing all six items in the first submission reduces the likelihood of a "pend for additional information" delay and is the single most effective step toward a faster approval.

Step Therapy Requirements

Step therapy, sometimes called "fail first," requires a patient to try and fail on one or more cheaper drugs before the insurer will cover the requested medication. BCBSTX applies step therapy to Farxiga on some commercial and marketplace plans.

For the type 2 diabetes indication, the most common step requirement is a documented trial of metformin (typically 500, 2 to 000 mg daily for at least 90 days) unless the patient has a contraindication such as an eGFR below 30 mL/min/1.73m² [9]. Some plans add a second step requiring a trial of a generic sulfonylurea (glipizide or glimepiride) before approving an SGLT2 inhibitor.

Texas passed Senate Bill 680, the step therapy reform law (effective September 1, 2017), which requires that exceptions to step therapy protocols be granted when:

• The required drug is contraindicated for the patient
• The patient previously failed the step drug (documented history counts)
• The required drug causes or is expected to cause an adverse reaction
• The patient is stable on the requested drug from a prior plan or prescription

If your physician can demonstrate any of these conditions, BCBSTX must grant the step therapy exception. The request goes through the same PA portal, and the 72-hour response window applies.

What Does Farxiga Actually Cost Under BCBSTX Plans?

Costs break into three components that stack differently depending on where a patient is in the plan year.

Before the deductible is met: Most BCBSTX commercial plans apply the full negotiated rate to prescription drugs until the annual deductible is satisfied. For Farxiga, the negotiated rate after the BCBSTX/AstraZeneca contract discount is typically in the $280, $400 range per 30-day supply, considerably below the retail list price but still a meaningful out-of-pocket spend.

After the deductible, before out-of-pocket maximum: Once the deductible clears, the Tier 3 copay applies. Depending on the specific plan design, this runs $50, $120 per 30-day fill or a coinsurance percentage (commonly 30%, 40% of the negotiated rate on some HDHP plans).

After the out-of-pocket maximum: Prescription costs reduce to $0 for the remainder of the plan year.

On a High Deductible Health Plan (HDHP) paired with a Health Savings Account (HSA), Farxiga costs count toward both the deductible and the out-of-pocket maximum, which can accelerate the point at which the patient reaches $0 cost if they have other medical expenses.

AstraZeneca Savings Programs and Patient Assistance

AstraZeneca offers two programs that can reduce Farxiga costs substantially for eligible patients.

AZ&Me Savings Card (commercially insured patients): Patients with commercial insurance (including BCBSTX plans) who meet eligibility criteria can pay as little as $0 per month for Farxiga through the AstraZeneca savings card program [10]. This card is not available to patients enrolled in Medicare Part D, Medicaid, or any other federal or state government-funded program. Income thresholds do not apply for commercially insured patients.

AZ&Me Patient Assistance Program: Uninsured patients or those whose insurance denies coverage may qualify for free Farxiga through this program. Annual household income must be at or below 600% of the federal poverty level. Applications are submitted through the AstraZeneca website or by calling 1-800-AZandME.

GoodRx and similar discount platforms can also reduce out-of-pocket costs when insurance coverage is absent or the copay exceeds the discount price, though using GoodRx means the expense does not count toward your deductible or out-of-pocket maximum.

Medicare Advantage and Part D Coverage Through BCBSTX

BCBSTX administers Medicare Advantage plans in Texas under the Blue Advantage brand. Part D drug coverage varies by plan, but Farxiga typically appears on the Medicare Part D formulary at Tier 3 or Tier 4. The Medicare Part D Inflation Reduction Act changes that took effect in 2024 cap out-of-pocket drug costs at $3,300 for the year (dropping to $2 to 000 in 2025), which benefits high-cost chronic-disease patients taking drugs like Farxiga year-round [11].

For Medicare patients, the AZ&Me savings card does not apply. AstraZeneca's separate Medicare patient assistance program or the Extra Help (Low Income Subsidy) program administered by the Social Security Administration may partially offset costs. Physicians should document the cardiovascular or CKD indication clearly, because some Part D formularies place Farxiga at a lower tier when dispensed for HFrEF or CKD than for diabetes alone.

How to Appeal a Farxiga Coverage Denial

BCBSTX denials most often cite one of three reasons: step therapy requirements not met, lack of medical necessity documentation, or the drug falling outside formulary for the enrolled plan.

Step 1: Internal Level 1 Appeal. Submit a written appeal within 180 days of the denial. Include the physician's letter of medical necessity, relevant lab values, and citations to clinical guidelines such as the 2024 ADA Standards of Care [6] or the 2022 AHA/ACC/HFSA Heart Failure Guidelines [7]. BCBSTX must respond within 30 days for standard appeals and 72 hours for expedited appeals.

Step 2: Internal Level 2 Appeal. If the Level 1 appeal fails, escalate to Level 2. A different clinical reviewer, not involved in the first decision, must evaluate the case.

Step 3: External Independent Review. Under Texas Insurance Code Chapter 4201, if both internal appeals fail, you have the right to request an independent review organization (IRO) review. The IRO decision is binding on BCBSTX. For life-threatening or urgent cases, this external review can be requested simultaneously with the internal appeal rather than sequentially. The Texas Department of Insurance (TDI) oversees this process and can be contacted at 1-800-252-3439 if BCBSTX fails to comply with statutory timelines.

A 2023 analysis of Part D coverage appeals published in the American Journal of Managed Care found that approximately 39% of initial denials for brand-name diabetes medications were overturned on appeal when complete clinical documentation was submitted [12]. Persistence through the full appeals process and thorough documentation are the most reliably effective strategies.

Farxiga for Heart Failure: A Coverage Nuance Most Patients Miss

Many BCBSTX members receive Farxiga for heart failure, not diabetes, but their physician inadvertently codes the prescription under a diabetes diagnosis. This matters for coverage because some plan formulary designs restrict Tier 3 Farxiga access to specific ICD-10 codes. If the claim is coded as E11.65 (Type 2 diabetes with hyperglycemia) but the plan's Farxiga coverage is structured primarily for cardiovascular benefit documentation, a mismatch can trigger an automatic pend or denial.

The DAPA-HF trial specifically enrolled patients with HFrEF regardless of diabetes status, and 42% of the trial's participants did not have type 2 diabetes [5]. The FDA label explicitly covers this population. When Farxiga is prescribed for HFrEF in a non-diabetic patient, the prescribing cardiologist should use I50.20, I50.43 as the primary ICD-10 code and attach the LVEF documentation from an echocardiogram. Sending the DAPA-HF citation alongside the PA request is not required, but it gives the BCBSTX clinical pharmacist reviewer a clear evidence basis to approve rather than pend the request.

For the CKD indication, the DAPA-CKD trial (N=4,304) showed a 39% reduction in the risk of sustained eGFR decline of at least 50%, end-stage kidney disease, or death from renal or cardiovascular causes versus placebo (P<0.001) [8]. Nephrologists filing PA requests for non-diabetic CKD patients should lead with those outcomes data and the N18.x diagnosis code rather than any diabetes code.

Switching Plans: How to Protect Farxiga Coverage at Renewal

If your employer changes carriers or you switch from a BCBSTX commercial plan to a marketplace plan during open enrollment, Farxiga coverage is not automatically preserved. Each new plan has its own PDL. Three actions protect continuity:

1. Search the new plan's PDL for dapagliflozin before enrolling, not after. Most insurers post their formularies publicly during open enrollment.
2. Ask your physician to submit a new PA request on the first day the new plan is active. Waiting until a refill is overdue creates a coverage gap.
3. Use the AstraZeneca savings card as a bridge if there is a lag between plans, since it is usable at most retail pharmacies nationwide.

Texas law does not require a new plan to honor a previous plan's PA approval, though some HCSC group plans carry over mid-year approvals when the same employer renews.

Specific BCBSTX Plan Types and Farxiga Coverage at a Glance

Blue Choice PPO (commercial group): Farxiga most commonly listed at Tier 3. PA required for some employer groups. Step therapy may apply for diabetes indication only.

Blue Advantage HMO: Formulary may differ from PPO. In-network pharmacy requirement is strict. Tier placement is similar, but the PA criteria can be more stringent on HMO products.

Blue Essentials (individual/marketplace): Tier and PA requirements depend on the metal level (Bronze, Silver, Gold). Gold plans on this product line have historically placed Farxiga at Tier 3 with the lowest copay share. Bronze plans with high deductibles mean members often pay the full negotiated rate for most of the plan year.

Blue Advantage Medicare (Part D): Tier 3 or Tier 4 placement depending on plan year and contracted negotiation. The $2,000 IRA out-of-pocket cap starting in 2025 changes the total annual exposure substantially [11].

Medicaid (managed by BCBSTX under STAR/CHIP): The Texas Medicaid preferred drug list is set by the Texas Health and Human Services Commission, not BCBSTX directly. Farxiga is listed on the Texas Medicaid PDL for type 2 diabetes with PA requirements aligned with the Texas Medicaid clinical criteria document.

If you have confirmed a Tier 3 PA approval for Farxiga under your BCBSTX commercial plan, request a 90-day supply through a mail-order pharmacy rather than 30-day retail fills. BCBSTX's mail-order pharmacy (Prime Therapeutics) typically applies a two-copay charge for a 90-day supply, reducing annual out-of-pocket cost by the equivalent of one full monthly copay.