XIGDUO XR 5/500 mg Tablet, Film Coated, Extended Release
Also known as Dapagliflozin And Metformin Hydrochloride. Coverage in Ohio (CMS PDP Region 14).
7 of 10 stand-alone Part D plans in Ohio cover this drug on tier 3.
7 of 7 plans apply a prior authorization, step therapy or quantity limit.
193 Medicare Advantage plans in OH 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. OH: 193 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)$7.60/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $18.6286 | $111.776 units |
|
| Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $18.6286 | $111.776 units |
|
| HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $19.0419 | $114.256 units |
|
| AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $20.2097 | $60.633 units |
|
| SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $19.4309 | $116.596 units |
|
| HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible | 3Preferred Brand | 21% | 21% | $19.0860 | $114.526 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible | 3Preferred Brand | 17% | 17% | $20.2097 | $60.633 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.