XIGDUO XR 2.5/1000 mg Tablet, Film Coated, Extended Release
Also known as Dapagliflozin And Metformin Hydrochloride. Coverage in Pennsylvania and West Virginia (CMS PDP Region 06).
9 of 12 stand-alone Part D plans in Pennsylvania and West Virginia cover this drug on tier 3.
9 of 9 plans apply a prior authorization, step therapy or quantity limit.
365 Medicare Advantage plans in PA, WV 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. PA: 306 plans · WV: 59 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $9.0500 | $54.306 units |
|
| Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $9.0500 | $54.306 units |
|
| SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $9.7155 | $58.296 units |
|
| AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible | 3Preferred Brand | 16% | 16% | $10.1513 | $60.916 units |
|
| HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $9.3567 | $56.146 units |
|
| HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible | 3Preferred Brand | 21% | 21% | $9.3552 | $56.136 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible | 3Preferred Brand | 16% | 16% | $10.1513 | $60.916 units |
|
| Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible | 3Preferred Brand | 25% | 25% | $9.4085 | $564.5160 units |
|
| Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $9.4228 | $565.3760 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.