XIGDUO XR 10/500 mg Tablet, Film Coated, Extended Release
Also known as Dapagliflozin And Metformin Hydrochloride. Coverage in Illinois (CMS PDP Region 17).
9 of 12 stand-alone Part D plans in Illinois cover this drug on tier 3.
9 of 9 plans apply a prior authorization, step therapy or quantity limit.
137 Medicare Advantage plans in IL 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. IL: 137 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% | $18.3733 | $55.123 units |
|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $18.3733 | $55.123 units |
|
| AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $20.7138 | $62.143 units |
|
| HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $18.9346 | $56.803 units |
|
| Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible | 3Preferred Brand | 20% | 20% | $20.3609 | $61.083 units |
|
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $19.4331 | $58.303 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible | 3Preferred Brand | 17% | 17% | $20.7138 | $62.143 units |
|
| HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible | 3Preferred Brand | 21% | 21% | $18.9288 | $56.793 units |
|
| Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $20.0179 | $60.053 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.