XIGDUO XR 5/500 mg Tablet, Film Coated, Extended Release
Also known as Dapagliflozin And Metformin Hydrochloride. Coverage in South Carolina (CMS PDP Region 09).
8 of 11 stand-alone Part D plans in South Carolina cover this drug on tier 3.
7 of 8 plans apply a prior authorization, step therapy or quantity limit.
80 Medicare Advantage plans in SC 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. SC: 80 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)$4.80/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $18.3779 | $110.276 units |
|
| Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $18.3779 | $110.276 units |
|
| HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $18.9235 | $113.546 units |
|
| SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $19.4581 | $116.756 units |
|
| AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $20.3268 | $60.983 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible | 3Preferred Brand | 17% | 17% | $20.3268 | $60.983 units |
|
| BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $19.2255 | — | None |
| HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible | 3Preferred Brand | 21% | 21% | $19.0025 | $114.026 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.