XIGDUO XR 5/500 mg Tablet, Film Coated, Extended Release
Also known as Dapagliflozin And Metformin Hydrochloride. Coverage in Virginia (CMS PDP Region 07).
6 of 9 stand-alone Part D plans in Virginia cover this drug on tier 3.
6 of 6 plans apply a prior authorization, step therapy or quantity limit.
122 Medicare Advantage plans in VA 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. VA: 122 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $18.4908 | $110.946 units |
|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $18.4908 | $110.946 units |
|
| AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $20.7237 | $62.173 units |
|
| SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $19.4309 | $116.596 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible | 3Preferred Brand | 17% | 17% | $20.7237 | $62.173 units |
|
| HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible | 3Preferred Brand | 22% | 22% | $19.1233 | $114.746 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.