What you need to know about Farxiga and Medicare Part D coverage

Whether Medicare Part D covers Farxiga depends on which Part D plan you have chosen and which pharmacy you use. Farxiga (dapagliflozin) is a diabetes and heart failure medication, and most Part D plans do cover it — but not all plans cover it the same way. Some plans may require you to try a different medication first, pay a higher copay, or use a specific pharmacy. The only way to know for certain is to check your own plan's formulary, which is the official list of drugs your plan will pay for.

Your out-of-pocket cost for Farxiga also depends on which stage of Part D coverage you are in during the year. Early in the year, you pay toward your deductible. Once you meet it, you enter the initial coverage stage where you pay a set copay or coinsurance. If your drug costs reach a certain threshold, you may enter the coverage gap, where you pay a higher percentage. Understanding these stages helps you predict what Farxiga will cost you month to month.

Key Takeaways

  • Most Medicare Part D plans cover Farxiga, but your specific plan's formulary determines whether it is covered and at what cost.
  • You can check your plan's formulary by calling the plan's customer service number (on your insurance card), visiting the plan's website, or calling Medicare at 1-800-MEDICARE.
  • Some plans may require prior authorization, meaning your doctor must get approval from the insurance company before you fill the prescription.
  • If your plan does not cover Farxiga or charges too much, you can switch to a different Part D plan during the annual open enrollment period (October 15 to December 7).
  • Patient information programs run by the drug manufacturer may help reduce your out-of-pocket cost even if your plan covers the drug.

How to check if your specific Part D plan covers Farxiga

Start by finding your plan's formulary. This document lists every drug your plan covers and tells you the copay or coinsurance amount you will pay. You can find it three ways: call the customer service number on the back of your Medicare card, visit your plan's website and search for "formulary," or call Medicare directly at 1-800-MEDICARE and ask them to look it up for you.

When you check the formulary, search for "dapagliflozin" (the generic name for Farxiga) as well as the brand name. Write down the tier level — this tells you how much you will pay. Tier 1 drugs usually have the lowest copay, while higher tiers cost more. Also note whether the plan lists any restrictions, such as "prior authorization required" or "step therapy" (meaning you must try another drug first).

If you cannot find the information online or over the phone, ask your doctor's office to check for you. Many offices have staff who regularly contact insurance companies and can get a quick answer about coverage and any restrictions.

What "prior authorization" and "step therapy" mean for Farxiga

Prior authorization means your doctor must contact your insurance company and get written approval before you can fill the prescription. This usually takes a few business days. Your doctor's office handles this — you do not need to do it yourself — but it does mean there may be a delay between when your doctor writes the prescription and when you can pick it up at the pharmacy.

Step therapy (also called "fail first") means your insurance company requires you to try a different, usually cheaper medication before they will pay for Farxiga. If that first medication does not work well for you or causes side effects, your doctor can then request that the plan cover Farxiga instead. Step therapy requirements vary by plan and sometimes by the reason your doctor prescribed Farxiga (diabetes versus heart failure, for example).

If your plan has either of these restrictions, talk to your doctor about whether it makes sense to start with the required medication or whether your doctor thinks Farxiga is necessary right away. Your doctor can sometimes appeal a step therapy requirement if they believe it is medically necessary to skip the first drug.

What to do if your plan does not cover Farxiga or the cost is too high

If your current Part D plan does not cover Farxiga, charges a very high copay, or requires step therapy you want to avoid, you have options. The most direct option is to switch to a different Part D plan during the annual open enrollment period, which runs from October 15 to December 7 each year. During this window, you can change to any other Part D plan available in your area without penalty.

Before you switch plans, use the Medicare Plan Finder tool at Medicare.gov to compare plans side by side. Enter Farxiga (or dapagliflozin) and your pharmacy, and the tool will show you which plans cover it and what your out-of-pocket cost would be under each plan. This takes about 10 minutes and can save you hundreds of dollars per year.

If you are outside the open enrollment period and your situation has changed — for example, your doctor just prescribed Farxiga for the first time — you may be able to make a change during a Special Enrollment Period. Call Medicare at 1-800-MEDICARE to ask whether a life event qualifies you.

Patient information programs that may lower your cost

AstraZeneca, the company that makes Farxiga, runs a patient information program called the AstraZeneca Foundation Patient information Program. This program can help reduce or eliminate your out-of-pocket cost if you meet income requirements. You can learn more by calling 1-800-292-6363 or visiting the AstraZeneca website.

These programs exist separately from your insurance coverage. Even if your Part D plan covers Farxiga, you may still be able to use a manufacturer program to reduce your copay. Some programs work by sending you a coupon or card that you use at the pharmacy to lower your cost at the point of sale. Others work by paying your copay directly to the pharmacy on your behalf.

Your doctor's office or pharmacist can also tell you about these programs. Many offices keep information about manufacturer information programs on file and can help you get your free guide.

Understanding your costs under Part D

Your Part D costs work in stages throughout the year. You pay a monthly premium to have the plan. When you fill a prescription, you pay a copay or coinsurance (a percentage of the drug's cost) until you have spent a certain amount out of pocket — this is called the deductible. After you reach your plan's deductible, you enter the "initial coverage" stage, where you pay a set copay or coinsurance for each prescription.

If your total drug costs reach a certain threshold (this amount changes each year), you enter the "coverage gap" or "donut hole," where you pay a higher percentage of the drug cost. Once your out-of-pocket spending reaches the catastrophic coverage threshold, Medicare pays most of the cost and you pay a small copay. Farxiga is a brand-name drug, so it typically falls into a higher tier than generic medications. This means your copay will likely be higher than it would be for a generic alternative. When you check your formulary, pay attention to whether a generic version of dapagliflozin is available and what its copay is, in case your doctor agrees it would work for you.

Questions to ask your doctor and pharmacist

Before you fill a prescription for Farxiga, ask your doctor: "Is there a generic version of this medication that would work as well for me?" and "If my insurance requires me to try a different medication first, do you think that is medically appropriate, or should we appeal that requirement?" These questions help you understand whether Farxiga is truly the best choice for your situation or whether a lower-cost alternative might work.

Ask your pharmacist: "What will my copay be for Farxiga under my Medicare plan?" and "Are there any manufacturer coupons or information programs available for this drug?" Your pharmacist can often answer these questions when ready and may have information about programs you did not know existed.

When to contact Medicare or your plan directly

Contact your Part D plan if you have questions about whether Farxiga is covered, what your copay will be, or whether prior authorization is required. You can reach them by calling the number on your insurance card. Have your prescription information ready (the drug name, dose, and quantity your doctor prescribed).

Contact Medicare at 1-800-MEDICARE if you want to file a complaint about your plan's coverage decision, if you believe your plan made an error, or if you want to know about switching plans outside the normal enrollment period. Medicare can also help you understand your rights if your plan denies coverage or if you disagree with a prior authorization decision.

Frequently Asked Questions

Does Medicare Part D always cover Farxiga?

Most Part D plans cover Farxiga, but not all do. Coverage depends on your specific plan's formulary. Some plans may not include it at all, while others cover it but with restrictions like prior authorization or step therapy. Check your plan's formulary to know for certain.

What is the difference between a copay and coinsurance for Farxiga?

A copay is a fixed dollar amount you pay each time you fill the prescription — for example, $35 per month. Coinsurance is a percentage of the drug's cost — for example, 25 percent. Your Part D plan will use one or the other, depending on the tier Farxiga is placed on and which stage of coverage you are in.

Can I appeal if my plan denies coverage for Farxiga?

Yes. You or your doctor can file an appeal with your Part D plan. Your doctor can also request an exception if they believe Farxiga is medically necessary and the plan's step therapy or prior authorization requirement should be waived. The plan must respond to an appeal within 72 hours for urgent requests.

Will switching Part D plans affect my other Medicare coverage?

No. Part D is prescription drug coverage only. Switching Part D plans does not affect your Part A (hospital) or Part B (medical) coverage, or your Medigap or Medicare Advantage plan if you have one. You can change Part D plans independently during open enrollment.

What happens if I cannot afford Farxiga even with my Part D coverage?

Talk to your doctor about lower-cost alternatives, look into the manufacturer's patient information program, or consider switching to a different Part D plan during open enrollment. You can also ask your doctor whether a generic version of dapagliflozin would work for you, as generics are usually cheaper than brand-name drugs.