Medicare AdvantageCoverageMedium impact
AB2026-07-004 Pharmacy updates
Capital Blue Cross·PA · Endocrinology, Internal Medicine, Family Medicine +1 more·Pharmacy
Effective date
Jul 1, 2026
We identified it
Jul 1, 2026
Summary
Effective July 1, 2026, Capital Blue Cross has removed Farxiga (brand name) from its formularies and replaced it with dapagliflozin (generic alternative) for antidiabetes treatment. Dapagliflozin requires step therapy (ST) and quantity level limits (QLL). Billing teams must update systems to reflect this formulary change and ensure prior authorization/step therapy requirements are applied.
Action Required
By July 1, 2026: Billing and clinical teams must update pharmacy systems and formulary databases to remove Farxiga and add dapagliflozin with step therapy (ST) and quantity level limits (QLL) requirements for all affected Capital Blue Cross plans (Elite, Exclusive, Advantage, and Value Plus across all product lines). Update prior authorization workflows to require step therapy verification before dapagliflozin claims are processed. Providers should receive notification about the formulary change to document prescribing decisions. Claims for Farxiga will likely be denied or require manual intervention after the effective date; claims for dapagliflozin without documented step therapy completion may be denied.