XIGDUO XR 5/500 mg Tablet, Film Coated, Extended Release
Also known as Dapagliflozin And Metformin Hydrochloride. Coverage in Connecticut, Massachusetts, Rhode Island and Vermont (CMS PDP Region 02).
8 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. 8 of 8 plans apply a prior authorization, step therapy or quantity limit.
152 Medicare Advantage plans in CT, MA, RI, VT 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: 42 plans · MA: 88 plans · RI: 20 plans · VT: 2 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)$16.40/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $18.3494 | $110.106 units |
|
| Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $19.0798 | $114.486 units |
|
| Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $18.3494 | $110.106 units |
|
| SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $19.4309 | $116.596 units |
|
| AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $20.2419 | $60.733 units |
|
| HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible | 3Preferred Brand | 21% | 21% | $19.0523 | $114.316 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible | 3Preferred Brand | 15% | 15% | $20.2419 | $60.733 units |
|
| Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible | 3Preferred Brand | $30.00 | $60.00 | $19.0798 | $114.486 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.