dapagliflozin (authorized generic to Farxiga) — Cigna
to reduce risk of cardiovascular death or hospitalization for heart failure or kidney disease progression as indicated per SGLT-2 inhibitors labeling
Preferred products
- Farxiga
- Jardiance
- Synjardy
- Synjardy XR
- Xigduo XR
Initial criteria
- Coverage for a Step 2 Product requires that the patient has a history within the 130-day look-back period of ONE of the following: (a) one Step 1 Product OR (b) one of the listed metformin-containing products (Glumetza ER, Riomet, metformin oral solution, metformin extended-release [generics to Fortamet ER and Glumetza ER], glyburide/metformin, glipizide/metformin, Actoplus Met, pioglitazone/metformin, Kazano, alogliptin/metformin, Jentadueto, Jentadueto XR, Kombiglyze XR, saxagliptin/metformin extended-release, Janumet, Janumet XR, sitagliptin/metformin [authorized generic to Zituvimet], Zituvimet, Zituvimet XR) OR (c) one Step 2 Product OR (d) one Step 3 Product.
- Coverage for a Step 3 Product requires that the patient has a history within the 130-day look-back period of ONE Step 2 Product.
Approval duration
1 year