SYNJARDY XR 12.5/1000 mg Tablet, Extended Release
Also known as Empagliflozin, Metformin Hydrochloride. Coverage in Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming (CMS PDP Region 25).
4 of 11 stand-alone Part D plans in Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming cover this drug on tier 3.
4 of 4 plans apply a prior authorization, step therapy or quantity limit.
189 Medicare Advantage plans in IA, MN, MT, NE, ND, SD, WY 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. IA: 37 plans · MN: 59 plans · MT: 25 plans · NE: 31 plans · ND: 18 plans · SD: 13 plans · WY: 6 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% | $5.4932 | $32.966 units |
|
| Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $5.4932 | $32.966 units |
|
| MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible | 3Preferred Brand | 22% | 22% | $5.9669 | $35.806 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible | 3Preferred Brand | 18% | 18% | $5.9427 | $35.666 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.