DraftcareoregonPolicy N/A

Dapagliflozin-containing products prior authorization

Customize your policy alerts

Sign up for all careoregon policy alerts

Know when careoregon releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This document governs prior authorization requirements for dapagliflozin and combination dapagliflozin/metformin products for CareOregon members, specifying clinical criteria and documentation required for approval.

Policy Summary

Payercareoregon

PolicyDapagliflozin-containing products prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and submit medical records documenting CKD stage, eGFR or uACR, and ACE/ARB optimization or documented contraindication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Lifetimeapproval length stated

eGFR 25-75renal function range cited

uACR >=30albuminuria threshold

NYHA II-IVHF functional class

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

DraftcareoregonPolicy N/A

Dapagliflozin-containing products prior authorization

Customize your policy alerts

Sign up for all careoregon policy alerts

Know when careoregon releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

Payercareoregon

PolicyDapagliflozin-containing products prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and submit medical records documenting CKD stage, eGFR or uACR, and ACE/ARB optimization or documented contraindication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Lifetimeapproval length stated

eGFR 25-75renal function range cited

uACR >=30albuminuria threshold

NYHA II-IVHF functional class

CKD Initial Therapy

Covered when ALL of the following are met for chronic kidney disease:

CKD Coverage: 1) Diagnosis of chronic kidney disease; 2) Submission of medical records (e.g., chart notes) documenting one of: Stage 2-4 CKD OR eGFR of 25-75 mL/min/1.73m2 OR urine albumin-to-creatinine ratio (uACR) >= 30 mg/g; 3) One of: patient is taking maximum tolerated doses of an ACE inhibitor OR an angiotensin II receptor blocker (ARB) OR submission of medical records documenting a contraindication to both an ACE inhibitor and an ARB.eGFR 25-75 mL/min/1.73m2; uACR >= 30 mg/g

Submit supporting medical records (chart notes) showing stage, eGFR, or uACR as applicable.

Heart Failure

Covered when criteria met for heart failure:

HF Coverage: 1) Diagnosis of heart failure; 2) Patient has New York Heart Association (NYHA) Class II to IV heart failure.

Diabetes (incomplete)

Covered when criteria met for diabetes (partial text present):

Diabetes Coverage (partial): Documented diagnosis of diabetes AND either: 1) patient has established atherosclerotic cardiovascular disease (ASCVD), OR 2) other criteria (source text incomplete).

Source text incomplete for full diabetes criteria; submit documentation of ASCVD when applicable.

No explicit exclusions are listed in the source policy for dapagliflozin-containing products.

Key Clinical Thresholds & Coding

eGFR — CKD cited range (25-75 mL/min/1.73m2)

eGFR range25-75 mL/min/1.73m2

Use in CKD criteriaOne acceptable documentation option for CKD coverage is an eGFR of 25-75 mL/min/1.73m2.

Evidence requiredSubmit medical records (e.g., chart notes) documenting the eGFR within this range.

uACR — urine albumin-to-creatinine ratio threshold

uACR threshold>= 30 mg/g

Use in CKD criteriaUrine albumin-to-creatinine ratio (uACR) greater than or equal to 30 mg/g qualifies as supporting documentation for CKD coverage.

Evidence requiredSubmit medical records (e.g., chart notes) documenting uACR >= 30 mg/g.

Provider Actions & Documentation Requirements

Prior Authorization

Prior authorization required; approval = lifetime

Prior authorization is required for dapagliflozin-containing products (generic dapagliflozin, Xigduo XR, and brand dapagliflozin/metformin). Approval length for authorized therapy is lifetime (through 12/31/2039 as listed).

Step Therapy

Optimize ACE inhibitor or ARB therapy (or document contraindication)

For the CKD indication, the patient must be taking maximum tolerated doses of an ACE inhibitor or an angiotensin II receptor blocker (ARB), or the provider must submit medical records documenting a contraindication to both an ACE inhibitor and an ARB.

Documentation Required

Submit supporting medical records (CKD stage, eGFR, or uACR)

Submit medical records (for example, chart notes) that document CKD stage, an eGFR value, or urine albumin-to-creatinine ratio (uACR) as applicable to support the request.

Acceptable documentation includes: Stage 2–4 CKD, eGFR 25–75 mL/min/1.73m2, or uACR ≥ 30 mg/g.

Denial Risk

Denial risk if documentation or clinical criteria are absent

Requests lacking the required medical record documentation (e.g., no documentation of CKD stage, eGFR, or uACR) or failing to meet the listed clinical criteria (diagnosis plus required lab/stage and ACE/ARB optimization or documented contraindication) will be subject to denial.

Missing documentation of Stage 2–4 CKD, eGFR 25–75 mL/min/1.73m2, or uACR ≥ 30 mg/g.
No evidence the patient is on maximum tolerated ACE inhibitor/ARB and no documented contraindication to both.

Background

Dapagliflozin-containing products are indicated in this policy for chronic kidney disease (CKD), heart failure, and certain cases of diabetes (diabetes criteria are partially specified in the source). For CKD the policy requires a diagnosis of CKD plus submission of medical records documenting one of: Stage 2–4 CKD, an eGFR of 25–75 mL/min/1.73m2, or a urine albumin-to-creatinine ratio (uACR) ≥ 30 mg/g. The CKD indication also requires either that the patient is taking maximum tolerated doses of an ACE inhibitor or an ARB or that records document a contraindication to both. For heart failure the policy covers patients with a diagnosis of heart failure who have NYHA Class II–IV symptoms. The diabetes indication references established atherosclerotic cardiovascular disease (ASCVD) or additional criteria, but the source text is incomplete for the full diabetes criteria.

Definitions

eGFR definition / range referenced for CKD

Definition / rangeeGFR 25-75 mL/min/1.73m2

Role in coverageAcceptable documentation for CKD initial authorization includes eGFR within this range or Stage 2-4 CKD.

DocumentationMedical records (chart notes) must show the eGFR value within 25-75 mL/min/1.73m2 when used to meet criteria.

uACR definition — urine albumin-to-creatinine ratio threshold

DefinitionUrine albumin-to-creatinine ratio (uACR) greater than or equal to 30 mg/g

Role in coverageuACR >= 30 mg/g is an acceptable laboratory criterion to support CKD coverage eligibility.

DocumentationSubmit chart notes documenting the uACR result to meet the CKD criteria.

NYHA Class II-IV — heart failure functional class eligible

NYHA class eligibleNew York Heart Association (NYHA) Class II to IV

Role in coveragePatients with a diagnosis of heart failure meet coverage criteria if documented as NYHA Class II–IV.

DocumentationMedical records must document the NYHA functional class to support heart failure coverage.

Initial Therapy Criteria

Initial CKD authorization

Initial authorization criteria summarized

Initial CKD: Diagnosis of CKD AND supporting documentation (Stage 2-4 OR eGFR 25-75 mL/min/1.73m2 OR uACR >= 30 mg/g) AND ACE/ARB optimization (maximum tolerated dose) or documentation of contraindication to both ACE inhibitor and ARB.eGFR 25-75 mL/min/1.73m2; uACR >= 30 mg/g

Providers must submit chart notes or other medical records to demonstrate each element.

Step	Requirement
1	Patient is taking maximum tolerated doses of an ACE inhibitor or an angiotensin II receptor blocker (ARB)
	OR submission of medical records (e.g., chart notes) documenting a contraindication to both an ACE inhibitor and an ARB

Policy Summary

Payercareoregon

PolicyDapagliflozin-containing products prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and submit medical records documenting CKD stage, eGFR or uACR, and ACE/ARB optimization or documented contraindication.

SourceLink

On This Page

Dapagliflozin-containing products prior authorization

Sign up for all careoregon policy alerts

Dapagliflozin-containing products prior authorization

Sign up for all careoregon policy alerts

Coverage Criteria

Key Clinical Thresholds & Coding

Provider Actions & Documentation Requirements

Background

Definitions

Initial Therapy Criteria

Continuation Criteria

Step Therapy / Optimization Requirements