Medicare's Coverage of Farxiga

Medicare Part D covers Farxiga, but whether your plan pays for it depends on your specific formulary — the list of drugs your plan covers. Most major Part D plans include Farxiga, but some require you to meet a deductible first, pay a copay or coinsurance, or get prior authorization from your doctor before the pharmacy will fill the prescription.

Farxiga (dapagliflozin) is a diabetes and heart failure medication. Because it is a brand-name drug, your out-of-pocket cost will be higher than for a generic alternative if one exists. The actual amount you pay depends on which Part D plan you have, what tier Farxiga sits on in that plan's formulary, and whether you have reached your deductible or entered the coverage gap.

If you have Original Medicare (Part A and B only) without Part D, Medicare does not cover Farxiga at all. You would need to enroll in a Part D plan during the annual enrollment period or a special enrollment period to get coverage.

Key Takeaways

  • Most Medicare Part D plans cover Farxiga, but you must check your specific plan's formulary to confirm it is included and what tier it is on.
  • You may need prior authorization from your doctor before your pharmacy will fill a Farxiga prescription, depending on your plan's rules.
  • Your out-of-pocket cost for Farxiga varies by plan, deductible status, and whether you are in the coverage gap, and can range from a standard copay to coinsurance of 25 to 33 percent.
  • If you have Original Medicare without Part D, you cannot get coverage for Farxiga unless you enroll in a Part D plan during an open or special enrollment period.

How to Check if Your Plan Covers Farxiga

The fastest way to confirm coverage is to log into your plan's website or call the customer service number on the back of your Medicare card. Have your prescription ready — you will need to give the pharmacy name and your doctor's name so the representative can look up the exact drug and dosage in your formulary.

When you call or check online, ask three things: whether Farxiga is on the formulary, what tier it is on (this determines your copay or coinsurance), and whether your plan requires prior authorization. If your plan does not cover Farxiga, you can switch to a different Part D plan during the annual enrollment period (October 15 to December 7 each year) or if you may have access to for a special enrollment period.

You can also use the Medicare Plan Finder tool on Medicare.gov. Enter your zip code, current medications, and preferred pharmacies, and the tool will show you which plans in your area cover those drugs and what the estimated costs would be.

What Prior Authorization Means and How It Works

Prior authorization is a requirement from your insurance plan that your doctor must get approval before the pharmacy fills your prescription. Some Part D plans require it for Farxiga because they want to confirm the drug is medically necessary for your condition before they pay for it.

If your plan requires prior authorization, your doctor's office usually handles the request. They submit your medical records and the reason for the prescription to your insurance plan, which reviews it and sends back an approval or denial within a few business days. Once approved, the pharmacy can fill your prescription. If denied, your doctor can appeal or discuss alternatives with you.

You can ask your doctor's office whether prior authorization is needed before you go to the pharmacy. This prevents a delay where you arrive to pick up the medication and learn the pharmacy cannot fill it yet.

Understanding Your Out-of-Pocket Costs

Your cost for Farxiga depends on where you are in the Medicare Part D benefit year and what tier your plan places the drug on. Most plans have four or five tiers, with generic drugs on the lowest tier and brand-name drugs on higher tiers. Farxiga, being a brand-name drug, is usually on tier 3 or 4.

Early in the year, before you meet your deductible, you pay the full price of Farxiga out of pocket. Once you meet your deductible (typically $505 to $550 in 2024, though this varies by plan), you move into the initial coverage phase and pay a copay or coinsurance. A copay is a flat dollar amount per prescription; coinsurance is a percentage of the drug's cost, usually 25 to 33 percent for brand-name drugs.

If your total drug spending reaches a certain threshold (around $5,850 in 2024), you enter the coverage gap, sometimes called the "donut hole." In the gap, you pay a larger share of the cost until your out-of-pocket spending reaches the catastrophic threshold (around $7,050 in 2024). After that, Medicare pays most of the cost and you pay only a small copay.

What to Do if Your Plan Does Not Cover Farxiga

If your current Part D plan does not cover Farxiga or places it on a tier with costs you cannot afford, you have options. During the annual enrollment period (October 15 to December 7), you can switch to a different Part D plan that does cover it. You can compare plans on Medicare.gov or call 1-800-MEDICARE for help.

If you need to start Farxiga before the next enrollment period, you may be able to request a special enrollment period. may have access to events include losing your current coverage, moving to a new state, or having a significant change in your health status. Contact your current plan or Medicare to ask if you may have access to.

Another option is to ask your doctor whether a generic alternative or a different medication might work for your condition. Some diabetes and heart failure drugs are available as generics and may have lower out-of-pocket costs under your plan.

How to Appeal if Your Claim Is Denied

If your plan denies coverage for Farxiga or if prior authorization is denied, you have the right to appeal. Your plan must send you a written explanation of the denial, including the reason and your appeal rights.

To appeal, contact your plan in writing within 60 days of the denial. Include your name, member ID, prescription details, and a brief explanation of why you believe the decision should be reversed. Your doctor can also submit a letter of medical necessity supporting the appeal. The plan must respond within 30 days.

If the plan upholds the denial, you can request an independent review by an outside organization, which is free. Your plan's denial letter will explain how to request this review.

Frequently Asked Questions

Does Medicare Part B cover Farxiga?

No. Part B covers certain drugs given in a hospital or doctor's office, but Farxiga is an oral medication you take at home, so it falls under Part D. You need a Part D plan to have coverage.

Can I use a GoodRx coupon or discount card instead of my Medicare coverage?

You can, but it is usually not allowed to use both at the same time. If the GoodRx price is lower than your Part D copay, you can choose to pay cash and use the coupon. However, this out-of-pocket spending does not count toward your Part D deductible or out-of-pocket maximum, so it may cost you more in the long run.

What if Farxiga is too expensive even with my Part D coverage?

Contact the drug manufacturer, AstraZeneca, to ask about patient information programs. Many pharmaceutical companies offer free or reduced-cost medication to people who meet income requirements. Your doctor's office or local health department can also help you find programs in your area.

Will my Part D plan cover Farxiga if my doctor prescribes it off-label?

Off-label use means the drug is prescribed for a condition other than what the FDA approved it for. Part D plans may cover off-label uses, but some require prior authorization or may deny the claim. Ask your plan directly whether it covers the specific condition your doctor is treating.