SYNJARDY XR 25/1000 mg Tablet, Extended Release
Also known as Empagliflozin, Metformin Hydrochloride. Coverage in Kansas (CMS PDP Region 24).
6 of 12 stand-alone Part D plans in Kansas cover this drug on tier 3.
6 of 6 plans apply a prior authorization, step therapy or quantity limit.
46 Medicare Advantage plans in KS 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. KS: 46 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible | 3Preferred Brand | 20% | 20% | $11.9149 | $35.743 units |
|
| Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $11.9049 | $35.713 units |
|
| Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $10.9710 | $32.913 units |
|
| Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $10.9710 | $32.913 units |
|
| Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible | 3Preferred Brand | 20% | 20% | $11.9049 | $35.713 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible | 3Preferred Brand | 15% | 15% | $11.9163 | $35.753 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.