XIGDUO XR 5/1000 mg Tablet, Film Coated, Extended Release
Also known as Dapagliflozin And Metformin Hydrochloride. Coverage in Oklahoma (CMS PDP Region 23).
8 of 11 stand-alone Part D plans in Oklahoma cover this drug on tier 3.
8 of 8 plans apply a prior authorization, step therapy or quantity limit.
71 Medicare Advantage plans in OK 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. OK: 71 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible | 3Preferred Brand | 16% | 16% | $10.1660 | $61.006 units |
|
| Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $9.2771 | $55.666 units |
|
| Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $9.2771 | $55.666 units |
|
| HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $9.5195 | $57.126 units |
|
| AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $10.2483 | $61.496 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible | 3Preferred Brand | 16% | 16% | $10.2483 | $61.496 units |
|
| HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible | 3Preferred Brand | 20% | 20% | $9.5183 | $57.116 units |
|
| Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $10.1599 | $60.966 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.