Does Oscar Health Cover Farxiga?
The verdict
Covered on most plans
Yes — Oscar Health covers Farxiga for type 2 diabetes, heart failure, and CKD on its commercial and ACA plans. Nationally, 92.1% of commercial and 96.6% of ACA plans cover Farxiga (MMIT, as of Sept 11, 2025). Oscar is a digital-first ACA and small-group insurer; it does not publish per-drug tier placements at the same detail level as large national plans. A metformin-first step therapy is consistent with the national commercial pattern (45.8%). Use Oscar's in-app drug lookup to confirm your tier and any step requirement. Generic dapagliflozin is now available.
Coverage is set by your specific plan and formulary. This is a research summary — always confirm with Oscar Health using your member ID.
Key facts
Farxiga carries the highest commercial step-therapy rate in its drug class: 45.8% of commercial plans require metformin-first step therapy (MMIT, as of Sept 11, 2025) — a pattern that applies to Oscar's commercial plans.
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 approximately $556, applicable to Oscar Medicare enrollees.
CMS Medicare Drug Price Negotiation Program, 2026 MFP
Generic dapagliflozin (Farxiga's active ingredient) is FDA-approved and available — potentially a lower-cost option on Oscar formularies.
FDA Drug Approvals and Databases
Medicare vs. commercial coverage
Whether Oscar Health 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
Oscar Health's Medicare footprint is limited compared to its ACA and commercial business. Where Oscar Medicare plans are offered, Farxiga is covered under Part D. The 2026 IRA negotiated Maximum Fair Price of $178.50 per 30-day supply applies (a 68% reduction from approximately $556). Prior authorization for Farxiga on Medicare is near-nil nationally (0.2% PA, 0.3% step per MMIT, Sept 11, 2025). The $2,100 annual out-of-pocket cap (CMS 2026 Part D redesign) applies to any Oscar Medicare enrollees. Verify whether Oscar offers Medicare plans in your state. Medicare beneficiaries cannot use commercial copay cards.
Commercial / Employer
Group & marketplace plans
Farxiga is covered on Oscar Health's commercial and ACA plans for its on-label indications (type 2 diabetes, heart failure, CKD). Nationally, 92.1% of commercial plans and 96.6% of ACA plans cover Farxiga (MMIT, Sept 11, 2025) — lower than other SGLT2s because step-therapy utilization management is very high. Nationally, 45.8% of commercial plans and 23.6% of ACA plans require step therapy, and 17.1% require PA (MMIT, Sept 11, 2025). Oscar's specific PA and step-therapy criteria are not confirmed in a primary public document at the drug level — a metformin-first step is consistent with the national commercial pattern. Oscar's plan-level tier and copay are not uniformly published publicly; use Oscar's in-app drug lookup for your exact information. Generic dapagliflozin is now available and may be covered at a lower tier than brand Farxiga — verify on the Oscar app. Oscar's Medicaid presence is limited; where available, Farxiga is covered with nominal cost-share and possible step therapy.
The 2 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.
Meet all 2 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
Oscar commercial/ACA: plan-specific cost-share not publicly published — verify on Oscar's in-app drug lookup. AstraZeneca reports an average commercial copay of approximately $26 (manufacturer-reported, not a guarantee). Any Oscar Medicare: IRA Maximum Fair Price $178.50 per 30-day supply effective January 1, 2026; $2,100 annual out-of-pocket cap applies. All figures are estimates — confirm with Oscar.
Typical monthly copay once prior authorization is approved.
Oscar does not publish per-drug copay amounts publicly. All cost-share must be confirmed through Oscar's app drug lookup or by calling member services. AstraZeneca's average commercial copay figure is manufacturer-reported and is not a guarantee of your specific Oscar plan cost. Consider asking about generic dapagliflozin as a potentially lower-cost option. Medicare beneficiaries cannot use 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
Use Oscar's app drug lookup to check Farxiga tier and step requirements
Log in to the Oscar app or oscarhealth.com and use the drug search tool. Search for Farxiga or dapagliflozin and select your specific plan. The tool shows your tier, estimated cost-share, and any step-therapy or PA flag. Also search for generic dapagliflozin to see if it is covered at a lower tier. Oscar's app is the primary source for per-drug cost data since tier information is not published in a standard public formulary.
- 2
Have your prescriber document metformin history before submitting a PA
If Oscar's step-therapy process is triggered for Farxiga, your prescriber must submit documentation showing an adequate trial of metformin at the maximum tolerated dose, or a clinical reason metformin was not appropriate (e.g., severe renal impairment, lactic acidosis risk). Your doctor can initiate this through Oscar's PA portal. Alternatively, ask your doctor whether generic dapagliflozin satisfies the step requirement on your plan.
- 3
Call Oscar member services for coverage details and next steps
Call the number on the back of your Oscar ID card and ask: (1) Is Farxiga covered on my plan, and what tier? (2) Is step therapy or PA required? (3) Is generic dapagliflozin covered at a lower tier? (4) If I have Oscar Medicare, what is my cost-share under the 2026 IRA price? Oscar's support team can walk you through any step or PA process.
Options if Oscar Health 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 now available and may carry lower cost-share on Oscar formularies than brand Farxiga. It may also satisfy any metformin-step requirement — verify on the Oscar app drug lookup.
Jardiance (empagliflozin)
Another SGLT2 inhibitor for T2D, heart failure, and CKD; no generic yet and a $197 IRA Medicare price. May carry a different step-therapy profile on Oscar plans — check the Oscar app.
Metformin (generic)
First-line generic diabetes medication at approximately $4/month; Tier 1 on virtually all formularies. Required as a prior step in many commercial and ACA 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 — Oscar covers Farxiga for type 2 diabetes, heart failure, and CKD on its commercial and ACA plans. Nationally, 92.1% of commercial and 96.6% of ACA plans cover Farxiga (MMIT, Sept 11, 2025). Oscar does not publish per-drug tier details publicly — use the Oscar app drug lookup to confirm your tier, any step-therapy requirement, and estimated cost-share for your specific plan.
A metformin-first step is likely. Nationally, 45.8% of commercial plans require step therapy before approving Farxiga — the highest rate of any SGLT2 drug (MMIT, Sept 11, 2025). Oscar's specific step criteria are not confirmed in a public primary source, but the national pattern suggests a metformin-first requirement is probable on Oscar commercial and ACA plans. Check the Oscar app for your specific plan's PA rules, and ask your prescriber to document your metformin history.
Generic dapagliflozin is FDA-approved and available. Oscar may cover it on your plan at a lower tier than brand Farxiga. Since Oscar does not post public formulary PDFs with drug-level tier data, use the Oscar app to search for both Farxiga and generic dapagliflozin to compare cost and coverage. If generic dapagliflozin is at a lower tier or satisfies the step-therapy requirement on your plan, it could be the more cost-effective option.
Oscar's Medicare presence is limited compared to its ACA and commercial business. Where Oscar Medicare plans exist, Farxiga is covered under Part D with the 2026 IRA negotiated Maximum Fair Price of $178.50 per 30-day supply. Prior authorization is near-nil on Medicare nationally (0.2% PA per MMIT). The $2,100 annual Part D out-of-pocket cap applies. Verify whether Oscar offers Medicare plans in your state at oscarhealth.com.
CMS negotiated a Farxiga Maximum Fair Price of $178.50 per 30-day supply, effective January 1, 2026 — a 68% cut from the prior list price of approximately $556. This price applies to Medicare Part D plans. For Oscar commercial and ACA plans, the IRA price does not directly govern commercial cost-share — your out-of-pocket is set by Oscar's plan design. For Medicare enrollees, this is the payer-side ceiling; actual cost depends on Oscar's cost-sharing structure. Verify via the Oscar app or member services.
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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 Oscar Health before making any decision. Consult a licensed healthcare provider and your plan administrator for guidance specific to your situation.