XIGDUO XR 10/1000 mg Tablet, Film Coated, Extended Release
Also known as Dapagliflozin And Metformin Hydrochloride. Coverage in Idaho and Utah (CMS PDP Region 31).
7 of 10 stand-alone Part D plans in Idaho and Utah cover this drug on tier 3.
7 of 7 plans apply a prior authorization, step therapy or quantity limit.
86 Medicare Advantage plans in ID, UT 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. ID: 38 plans · UT: 48 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% | $18.7168 | $56.153 units |
|
| Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $18.7168 | $56.153 units |
|
| SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $19.4309 | $58.293 units |
|
| HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $18.8247 | $56.473 units |
|
| AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $20.3633 | $61.093 units |
|
| HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible | 3Preferred Brand | 21% | 21% | $18.8910 | $56.673 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible | 3Preferred Brand | 17% | 17% | $20.3633 | $61.093 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.