XIGDUO XR 5/1000 mg Tablet, Film Coated, Extended Release
Also known as Dapagliflozin And Metformin Hydrochloride. Coverage in California (CMS PDP Region 32).
9 of 12 stand-alone Part D plans in California cover this drug on tier 3.
9 of 9 plans apply a prior authorization, step therapy or quantity limit.
298 Medicare Advantage plans in CA 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. CA: 298 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $9.3855 | $56.316 units |
|
| Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $9.1220 | $54.736 units |
|
| Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $9.1220 | $54.736 units |
|
| HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $9.3859 | $56.326 units |
|
| SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $9.7157 | $58.296 units |
|
| AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $10.1212 | $60.736 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible | 3Preferred Brand | 15% | 15% | $10.1212 | $60.736 units |
|
| Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $9.7839 | $587.0360 units |
|
| Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible | 3Preferred Brand | 19% | 19% | $9.7839 | $587.0360 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.