TRIJARDY XR 25/5/1000 mg Tablet, Extended Release
Also known as Empagliflozin, Linagliptin, Metformin Hydrochloride. Coverage in Hawaii (CMS PDP Region 33).
4 of 8 stand-alone Part D plans in Hawaii cover this drug on tier 3.
4 of 4 plans apply a prior authorization, step therapy or quantity limit.
32 Medicare Advantage plans in HI 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. HI: 32 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $11.4800 | $34.443 units |
|
| Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $10.7063 | $32.123 units |
|
| Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $10.7063 | $32.123 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible | 3Preferred Brand | 17% | 17% | $11.8832 | $35.653 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.