Does UnitedHealthcare Cover Farxiga?
The verdict
Covered on most plans
Yes — UnitedHealthcare covers Farxiga for type 2 diabetes, heart failure, and CKD across commercial, ACA, Medicare Advantage/Part D, and Medicaid via OptumRx. Nationally, 92.1% of commercial, 96.6% of ACA, and 95.1% of Medicare plans cover Farxiga (MMIT, as of Sept 11, 2025). The dominant commercial story: OptumRx's Step Therapy program frequently applies a metformin-first requirement to Farxiga — 45.8% of commercial plans have step therapy, the highest in this drug class. On Medicare, the picture flips: PA is near-nil (0.2%) and the 2026 IRA price of $178.50 per 30-day supply applies.
Coverage is set by your specific plan and formulary. This is a research summary — always confirm with UnitedHealthcare using your member ID.
Key facts
UHC/OptumRx commercial plans require step therapy for Farxiga in 45.8% of cases — the highest step-therapy rate of any SGLT2 inhibitor (MMIT, as of Sept 11, 2025).
MMIT via GoodRx (as of Sept 11, 2025)
The 2026 IRA negotiated Maximum Fair Price for Farxiga is $178.50 per 30-day supply — a 68% reduction from the prior list price of approximately $556.
CMS Medicare Drug Price Negotiation Program, 2026 MFP
Generic dapagliflozin (Farxiga's active ingredient) is FDA-approved and available — a potential lower-cost option on OptumRx formularies.
FDA Drug Approvals and Databases
Medicare vs. commercial coverage
Whether UnitedHealthcare covers Farxiga depends heavily on which kind of plan you hold. They follow completely different rules — here's each one, side by side.
Medicare
Part D & Advantage plans
Farxiga is covered on UnitedHealthcare's Medicare Advantage (Advantage 3-Tier PDL) and stand-alone Part D plans. Prior authorization and step therapy are essentially nil for Farxiga on Medicare — nationally 0.2% PA and 0.3% step (MMIT, as of Sept 11, 2025). UHC is required to carry Farxiga at the IRA negotiated Maximum Fair Price of $178.50 per 30-day supply, effective January 1, 2026 (a 68% reduction from approximately $556). The $2,100 annual out-of-pocket cap (CMS 2026 Part D redesign) applies. AstraZeneca reports an average Medicare Part D out-of-pocket of approximately $38.82 per month (manufacturer-reported, not a guarantee). Medicare beneficiaries cannot use manufacturer commercial copay cards.
Commercial / Employer
Group & marketplace plans
Farxiga is covered on UnitedHealthcare commercial and ACA plans via OptumRx, with 92.1% commercial and 96.6% ACA coverage nationally (MMIT, Sept 11, 2025). The key UHC/OptumRx nuance: OptumRx's Step Therapy program applies a metformin-first requirement to Farxiga in 45.8% of commercial plans nationally and 17.1% require PA (MMIT, Sept 11, 2025) — these are the highest utilization-management rates in this drug class. ACA plans show 23.6% step therapy. In practice, many UHC employer commercial plans will require documentation that metformin was tried at maximum tolerated dose before approving Farxiga. UHC Community Plan Medicaid covers Farxiga (MMIT Medicaid 99.8%) with PA required in 30.6% of plans and step therapy in 25.4%. AstraZeneca's average commercial copay is approximately $26 (manufacturer-reported, not a guarantee). Generic dapagliflozin is now available — verify whether your OptumRx plan covers it at a lower tier.
The 4 boxes you must tick to get approved
Commercial plans that will consider Farxiga require prior authorization. Check off what applies to you to see how close you are — this is a guide, not a guarantee of approval.
0 of 4 requirements selected. Meet all 4 and you have a documented case for approval. Missing any one is the most common reason requests are denied.
Your cost, three ways
What Farxiga actually costs you swings enormously depending on how it's covered. Here's the realistic range.
Paying cash
Approximately $400–$600+ per 30-day supply at retail pharmacy for brand Farxiga (pharmacy-variable estimate). Generic dapagliflozin is available at lower cost — verify price at your pharmacy.
List price with no coverage — before any manufacturer savings card.
With coverage
Medicare Part D: IRA Maximum Fair Price $178.50 per 30-day supply effective January 1, 2026; $2,100 annual out-of-pocket cap in 2026; AstraZeneca average Part D OOP ~$38.82/month (manufacturer-reported, not a guarantee). Commercial/ACA: AstraZeneca average commercial copay ~$26 (manufacturer-reported, not a guarantee); tier varies by OptumRx plan. Medicaid: $0–$10 nominal. All figures are estimates — confirm on your OptumRx formulary.
Typical monthly copay once prior authorization is approved.
All dollar figures are estimates and vary by OptumRx plan design, tier, pharmacy, and benefit phase. AstraZeneca figures are manufacturer-reported averages, not a guarantee of your specific cost. The IRA Maximum Fair Price of $178.50 is a ceiling on what your Medicare plan pays — your out-of-pocket depends on copay vs. coinsurance structure. Consider whether generic dapagliflozin is covered on your plan at a lower tier. Medicare beneficiaries cannot use manufacturer commercial copay cards.
Check YOUR exact coverage in 3 steps
General answers only get you so far. Here's how to confirm your own plan's decision in a few minutes.
- 1
Look up Farxiga on UHC's OptumRx formulary tool
Log in to myuhc.com or optumrx.com and use the drug formulary search for Farxiga (or dapagliflozin). Select your specific 2026 plan to see tier placement, any PA or step-therapy flag, and estimated cost-share. Also check whether generic dapagliflozin is listed at a lower tier on your plan.
- 2
Have your prescriber document metformin history if a step is required
If OptumRx's Step Therapy program triggers for your UHC commercial plan, your prescriber must document that you have tried metformin at the highest tolerated dose, or that metformin is contraindicated for you (e.g., renal impairment, lactic acidosis history). Your doctor can submit this through the UHC/OptumRx prior-authorization portal. On Medicare, this step is not required.
- 3
Call UHC member services to confirm 2026 cost-share and step requirements
Call the number on the back of your UHC ID card and ask: (1) What tier is Farxiga on my 2026 plan? (2) Does my plan require a step therapy or PA for Farxiga? (3) Is generic dapagliflozin covered at a lower tier? (4) What will my out-of-pocket be per fill after my deductible? Your pharmacist can also run a real-time OptumRx eligibility check.
Options if UnitedHealthcare won't cover Farxiga
A denial isn't the end of the road. These are the paths people commonly explore next — discuss any of them with your prescriber.
Generic dapagliflozin (Farxiga generic)
FDA-approved generic dapagliflozin is available and may carry lower cost-share on OptumRx formularies than brand Farxiga. Verify tier on your UHC plan formulary.
Jardiance (empagliflozin)
Another SGLT2 inhibitor; covered on UHC/OptumRx plans. The 2026 IRA negotiated price for Jardiance is $197 per 30-day supply. UHC commercial plans also commonly require metformin-first step for Jardiance. Discuss with your prescriber.
Metformin (generic)
First-line generic diabetes medication; Tier 1 at approximately $4/month on all OptumRx formularies. Required as a prior step in many UHC commercial and Medicaid plans before Farxiga is approved.
These options are listed for information only — your own clinician decides what is appropriate for you.
Frequently Asked Questions
Yes — UnitedHealthcare covers Farxiga for type 2 diabetes, heart failure, and CKD across all lines of business via OptumRx. Nationally, 92.1% of commercial and 95.1% of Medicare plans cover it (MMIT, Sept 11, 2025). On commercial plans, 45.8% require a metformin-first step — the highest step rate in this drug class. On Medicare, PA is near-nil. Verify tier and step requirements on your specific OptumRx formulary at optumrx.com.
OptumRx's Step Therapy program applies a metformin-first requirement to Farxiga in approximately 45.8% of commercial plans nationally (MMIT, Sept 11, 2025) — the highest step rate of any SGLT2 in this batch. Metformin is established as first-line therapy for type 2 diabetes. OptumRx requires documentation that metformin was tried at maximum tolerated dose or is contraindicated before approving the more expensive branded SGLT2. This step does not apply on UHC Medicare Advantage plans (0.3% step nationally).
Generic dapagliflozin is FDA-approved and available. OptumRx plans are updating their 2026 formularies and may cover generic dapagliflozin at a lower tier than brand Farxiga. If generic dapagliflozin satisfies the step-therapy requirement on your UHC commercial plan, it could also resolve any step requirement. Verify whether generic dapagliflozin is on your specific OptumRx formulary and at what tier by searching at optumrx.com.
CMS negotiated a Farxiga Maximum Fair Price of $178.50 per 30-day supply, effective January 1, 2026 — a 68% reduction from approximately $556. UHC's Medicare Advantage and Part D plans must apply this as a payer-side ceiling. AstraZeneca reports an average Medicare Part D out-of-pocket of approximately $38.82 per month (manufacturer-reported, not a guarantee). The $2,100 annual Part D out-of-pocket cap also applies in 2026.
Prior authorization is essentially not required for Farxiga on UHC Medicare Advantage and Part D — only 0.2% of Medicare plans require it nationally (MMIT, Sept 11, 2025). On UHC commercial plans, PA is required in 17.1% nationally and 45.8% have step therapy. On Medicaid, PA is required in 30.6% of plans. The Medicare experience is significantly easier than commercial or Medicaid.
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Read moreThis content is for informational purposes only and does not constitute medical, financial, or insurance advice. Coverage rules, prior-authorization criteria, and copay amounts change frequently and vary by plan, formulary tier, and effective date — always verify current benefits directly with UnitedHealthcare before making any decision. Consult a licensed healthcare provider and your plan administrator for guidance specific to your situation.