XIGDUO XR 10/500 mg Tablet, Film Coated, Extended Release
Also known as Dapagliflozin And Metformin Hydrochloride. Coverage in Indiana and Kentucky (CMS PDP Region 15).
7 of 10 stand-alone Part D plans in Indiana and Kentucky cover this drug on tier 3.
7 of 7 plans apply a prior authorization, step therapy or quantity limit.
219 Medicare Advantage plans in IN, KY 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. IN: 116 plans · KY: 103 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)$8.60/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $18.6090 | $55.833 units |
|
| Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $18.6090 | $55.833 units |
|
| SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $19.4750 | $58.433 units |
|
| HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $19.0227 | $57.073 units |
|
| AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $20.4037 | $61.213 units |
|
| HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible | 3Preferred Brand | 20% | 20% | $19.0588 | $57.183 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible | 3Preferred Brand | 18% | 18% | $20.4037 | $61.213 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.