XULTOPHY 100/3.6 100/3.6 [iU]/mL/mg/mL Injection, Solution
Also known as Insulin Degludec And Liraglutide. Coverage in Wisconsin (CMS PDP Region 16).
1 of 10 stand-alone Part D plans in Wisconsin cover this drug on tier 3.
1 of 1 plans apply a prior authorization, step therapy or quantity limit.
19 Medicare Advantage plans in WI 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. WI: 19 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $88.0424 | $1,320.6415 units |
|
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.