XIGDUO XR 5/500 mg Tablet, Film Coated, Extended Release
Also known as Dapagliflozin And Metformin Hydrochloride. Coverage in Kansas (CMS PDP Region 24).
9 of 12 stand-alone Part D plans in Kansas cover this drug on tier 3.
9 of 9 plans apply a prior authorization, step therapy or quantity limit.
77 Medicare Advantage plans in KS 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. KS: 77 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible | 3Preferred Brand | 20% | 20% | $20.5794 | $61.743 units |
|
| Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $20.5794 | $61.743 units |
|
| HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $19.1523 | $114.916 units |
|
| Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $18.8855 | $113.316 units |
|
| Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $18.8855 | $113.316 units |
|
| Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible | 3Preferred Brand | 20% | 20% | $20.5794 | $61.743 units |
|
| SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $19.4309 | $116.596 units |
|
| AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $20.4159 | $61.253 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible | 3Preferred Brand | 15% | 15% | $20.4159 | $61.253 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.