Medicare coverage for Farxiga depends on your specific plan and diagnosis

Farxiga (dapagliflozin) is a medication used to treat heart failure, chronic kidney disease, and type 2 diabetes. Whether Medicare pays for it depends on which Medicare plan you have, which condition you're being treated for, and whether your doctor's prescription meets the plan's requirements. Original Medicare (Part B) covers some uses, Medicare Advantage plans set their own rules, and Part D plans cover the drug version for diabetes — but you'll need to check your specific plan's formulary, which is the official list of drugs it covers.

The fastest way to know for certain is to call your plan directly or log into your plan's website and search for Farxiga. You can also ask your doctor's office to check coverage before you fill the prescription, which saves time and prevents surprises at the pharmacy.

Key Takeaways

  • Original Medicare Part B may cover Farxiga when given by injection for heart failure or kidney disease, but Part D (prescription drug coverage) does not cover the injectable form.
  • Medicare Advantage plans each maintain their own formulary, so coverage varies by plan and by the condition being treated.
  • Your doctor's office can contact your plan to verify coverage before you fill a prescription, which is faster than calling yourself.
  • If your plan does not cover Farxiga, you can ask your doctor about a generic alternative, request a coverage exception, or switch plans during open enrollment.

How Original Medicare Part B covers Farxiga

Original Medicare Part B covers Farxiga when it is administered by injection in a doctor's office or hospital outpatient setting. This typically applies to treatment of heart failure or chronic kidney disease. Part B pays 80 percent of the approved amount after you meet your annual deductible, and you pay the remaining 20 percent as coinsurance.

If your doctor prescribes Farxiga as a tablet for type 2 diabetes, Original Medicare Part B does not cover it — that would fall under Part D prescription drug coverage instead. The tablet form is not covered by Part B because it is an oral medication taken at home, not an injection given in a medical setting.

What Medicare Advantage plans cover

Medicare Advantage plans (Part C) are required to cover at least as much as Original Medicare does, but each plan decides what else to include. Some plans cover the Farxiga tablet for diabetes; others do not. Some plans may cover it for heart failure or kidney disease with fewer restrictions than Original Medicare.

Your plan's formulary is the document that lists exactly which drugs are covered and at what cost tier (how much you pay out of pocket). You can find your plan's formulary on your plan's website, or call the customer service number on your insurance card. Search for "dapagliflozin" or "Farxiga" to see whether it is listed and what tier it is on — Tier 1 costs less than Tier 4.

Part D prescription drug coverage for the tablet form

If you take Farxiga as a tablet for type 2 diabetes, your coverage comes from a Part D plan, not Part B. Part D plans vary widely in whether they cover Farxiga and at what cost. Some plans include it on their formulary with a low copay; others require you to try a different diabetes medication first, or they may not cover it at all.

To check your Part D plan's coverage, log into your plan's website and search the formulary for Farxiga or dapagliflozin. If the drug is listed, note the tier number — that tells you your copay. If it is not listed, you can ask your doctor to request a coverage exception, which is a formal request for the plan to cover a drug that is not on the formulary.

What to do if your plan does not cover Farxiga

If your plan's formulary does not include Farxiga, you have several options. First, ask your doctor whether a generic alternative or a different medication in the same drug class would work for your condition. Your plan may cover a similar drug at a lower cost.

Second, you can request a coverage exception. Your doctor submits a written request to your plan explaining why Farxiga is medically necessary for you and why other covered drugs would not work. The plan has 72 hours to respond. If the plan denies the exception, you can file an appeal.

Third, if you are in a Medicare Advantage plan, you can switch to Original Medicare plus a Part D plan during the Annual Enrollment Period (October 15 to December 7 each year). If you have a may have access to life event — such as moving, losing other coverage, or a major change in your health — you may be able to switch outside the enrollment period.

How to verify coverage before you fill the prescription

The best time to check coverage is before your doctor sends the prescription to the pharmacy. Ask your doctor's office to call your insurance plan and verify that Farxiga is covered for your diagnosis. Provide the office with your Medicare plan name and member ID number, which is on your insurance card.

Your doctor's office can also ask the plan whether prior authorization is required — that is, whether the plan needs to approve the prescription before the pharmacy can fill it. If prior authorization is needed, the office can request it right away instead of waiting for the pharmacy to call later. This can speed up the process by several days.

If you prefer to check yourself, call the customer service number on your insurance card and ask whether Farxiga is covered for your condition. Have your member ID ready. Write down the representative's name, the date, and what they told you in case you need to reference it later.

Cost and copay information

If your plan covers Farxiga, your out-of-pocket cost depends on which tier the drug is on. Tier 1 drugs (preferred generics) usually cost $10 to $15 per prescription. Tier 2 (preferred brand-name drugs) might cost $35 to $50. Tier 3 and Tier 4 drugs can cost $75 or more per prescription, depending on your plan.

If Farxiga is on a high tier and the cost is more than you can afford, ask your doctor whether the manufacturer offers a patient information program. Many drug manufacturers provide discounts or free medication to people who meet income requirements. Your doctor's office or the pharmacy can help you find out whether you may have access to.

Frequently Asked Questions

Does Original Medicare cover Farxiga for type 2 diabetes?

Original Medicare Part B does not cover the Farxiga tablet for diabetes because it is an oral medication taken at home. Part D prescription drug plans cover the tablet form, but coverage varies by plan. You need to check your specific Part D formulary to see whether it is included.

What is the difference between Farxiga coverage under Part B and Part D?

Part B covers Farxiga when it is injected in a doctor's office for heart failure or kidney disease. Part D covers the tablet form for diabetes taken at home. They are different routes of administration and different coverage categories, so you need to know which form your doctor prescribed.

Can I switch Medicare plans if my current plan does not cover Farxiga?

Yes, but only during the Annual Enrollment Period (October 15 to December 7) or if you have a may have access to life event such as moving or losing other coverage. If you are in a Medicare Advantage plan, you can switch to Original Medicare plus a Part D plan. If you are in Original Medicare, you can change your Part D plan during enrollment.

What happens if my doctor requests a coverage exception and the plan says no?

You have the right to appeal the denial. Your doctor can file a formal appeal with the plan within 60 days of the denial. If the plan denies the appeal again, you can request an independent review through Medicare. The process takes time, so ask your doctor whether a covered alternative medication is available while the appeal is pending.

How do I know if my plan requires prior authorization for Farxiga?

Call your plan's customer service number or check your plan's website. Ask whether prior authorization is required for Farxiga for your specific diagnosis. If it is, your doctor's office can request it before sending the prescription to the pharmacy, which speeds up the process.