XULTOPHY 100/3.6 100/3.6 [iU]/mL/mg/mL Injection, Solution
Also known as Insulin Degludec And Liraglutide. Coverage in Connecticut, Massachusetts, Rhode Island and Vermont (CMS PDP Region 02).
3 of 11 stand-alone Part D plans in Connecticut, Massachusetts, Rhode Island and Vermont cover this drug on tier 3.
Lowest 30-day cost $30.00 at a preferred pharmacy. 3 of 3 plans apply a prior authorization, step therapy or quantity limit.
49 Medicare Advantage plans in CT, MA, RI do cover it
Medicare Advantage plans carry their own formularies, separate from stand-alone Part D. A patient on an MA-PD plan may have coverage even where no PDP lists the drug. CT: 17 plans · MA: 27 plans · RI: 5 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $85.3221 | $1,279.8315 units |
|
| SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $87.9729 | $1,319.5915 units |
|
| Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible | 3Preferred Brand | $30.00 | $60.00 | $85.3221 | $1,279.8315 units |
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Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity.