XIGDUO XR 5/1000 mg Tablet, Film Coated, Extended Release
Also known as Dapagliflozin And Metformin Hydrochloride. Coverage in Missouri (CMS PDP Region 18).
7 of 10 stand-alone Part D plans in Missouri cover this drug on tier 3.
7 of 7 plans apply a prior authorization, step therapy or quantity limit.
141 Medicare Advantage plans in MO 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. MO: 141 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)$9.60/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $9.2375 | $55.436 units |
|
| Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $9.2375 | $55.436 units |
|
| HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $9.4846 | $56.916 units |
|
| AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $10.2470 | $61.486 units |
|
| HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible | 3Preferred Brand | 20% | 20% | $9.4852 | $56.916 units |
|
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $9.7240 | $58.346 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible | 3Preferred Brand | 17% | 17% | $10.2470 | $61.486 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.