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HumanaMedicare Advantage · Prior Auth · Medicare Advantage · Endocrinology, Cardiology, Nephrology +2 moreHigh impact

Farxiga (dapagliflozin) (New)

Act
by Jan 1, 2027
Effective date
Jan 1, 2027
Identified
Sep 30, 2026

Summary

Humana Medicare Advantage has implemented a new prior authorization policy for Farxiga (dapagliflozin) effective January 1, 2027, covering three indications: Type 2 Diabetes Mellitus, Heart Failure, and Chronic Kidney Disease at Risk of Progression. The policy requires prior authorization for brand Farxiga when generic dapagliflozin has not been tried or cannot be used, with specific clinical criteria and exclusions for each indication.

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What to do

by Jan 1, 2027 · 9 steps
01Billing team must implement prior authorization requirements for all Farxiga (dapagliflozin) prescriptions in the billing and EMR systems.
02Update pharmacy billing software to require prior auth submission before claims are processed for brand Farxiga tablets.
03Create or update prior auth templates to include: confirmation that member has tried or cannot use generic dapagliflozin tablet, documented diagnosis (T2DM, Heart Failure, or CKD at risk of progression), and relevant clinical parameters (eGFR for T2DM indication, absence of polycystic kidney disease and immunosuppressive therapy for CKD indication).
04Train billing and clinical staff on the three distinct approval pathways and their specific criteria/exclusions.
05For Type 2 Diabetes indication: flag claims where member's eGFR is less than 45 mL/min/1.73 m² to prevent inappropriate approval.
06For Chronic Kidney Disease indication: flag claims for members with polycystic kidney disease or recent immunosuppressive therapy as non-approvable.
07Establish workflow to route all Farxiga prior auth requests through Humana's PAL system (www.humana.com/PAL).
08Failure to obtain prior authorization will result in claim denials.
09All approvals are limited to the initial plan year and will require reauthorization for subsequent years.

Original notice

Farxiga (dapagliflozin) (New)
mcp.humana.com · Always check the source before changing claims.
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Humana policiesEndocrinologyCardiologyNephrologyInternal MedicinePharmacy

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