TRIJARDY XR 5/2.5/1000 mg Tablet, Extended Release
Also known as Empagliflozin, Linagliptin, Metformin Hydrochloride. Coverage in Pennsylvania and West Virginia (CMS PDP Region 06).
6 of 12 stand-alone Part D plans in Pennsylvania and West Virginia cover this drug on tier 3.
6 of 6 plans apply a prior authorization, step therapy or quantity limit.
321 Medicare Advantage plans in PA, WV 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. PA: 263 plans · WV: 58 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)$8.20/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $5.3437 | $32.066 units |
|
| Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $5.3437 | $32.066 units |
|
| SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $5.7400 | $34.446 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible | 3Preferred Brand | 16% | 16% | $5.8991 | $35.396 units |
|
| Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible | 3Preferred Brand | 25% | 25% | $5.5212 | $331.2760 units |
|
| Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $5.4869 | $329.2160 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.