GLYBURIDE AND METFORMIN HYDROCHLORIDE 1.25/250 mg Tablet, Film Coated
Package: 100 TABLET, FILM COATED in 1 BOTTLE (65862-080-01). NDC 65862008001.
- Plans covering it
- 17
- across 39 regions checked
- Lowest tier
- 1
- lower tiers cost less
- Plans with restrictions
- 12
- prior auth, step therapy or quantity limit
Coverage by region
Covered by at least one plan in 13 of 39 CMS regions; no plan covers it in 26.
| Region | Plans covering | Tiers | Lowest 30-day cost | Restrictions |
|---|---|---|---|---|
| Pennsylvania and West Virginia | 2 of 12 | 2 | $5.00 | none |
| Michigan | 2 of 12 | 1 | $1.00 | 2 of 2 plans |
| Kansas | 2 of 12 | 3 | — | 2 of 2 plans |
| California | 2 of 12 | 4 | — | none |
| New Jersey | 1 of 12 | 3 | — | 1 of 1 plans |
| North Carolina | 1 of 12 | 3 | $45.00 | 1 of 1 plans |
| South Carolina | 1 of 11 | 6 | $5.00 | none |
| Florida | 1 of 10 | 6 | $0.00 | 1 of 1 plans |
| Alabama and Tennessee | 1 of 12 | 3 | $47.00 | 1 of 1 plans |
| Illinois | 1 of 12 | 3 | — | 1 of 1 plans |
| Texas | 1 of 12 | 3 | — | 1 of 1 plans |
| Oklahoma | 1 of 11 | 3 | — | 1 of 1 plans |
| New Mexico | 1 of 11 | 3 | — | 1 of 1 plans |
| Maine and New Hampshire | no PDP | — | — | — |
| Connecticut, Massachusetts, Rhode Island and Vermont | no PDP | — | — | — |
| New York | no PDP | — | — | — |
| Delaware, DC and Maryland | no PDP | — | — | — |
| Virginia | no PDP | — | — | — |
| Georgia | no PDP | — | — | — |
| Ohio | no PDP | — | — | — |
| Indiana and Kentucky | no PDP | — | — | — |
| Wisconsin | no PDP | — | — | — |
| Missouri | no PDP | — | — | — |
| Arkansas | no PDP | — | — | — |
| Mississippi | no PDP | — | — | — |
| Louisiana | no PDP | — | — | — |
| Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming | no PDP | — | — | — |
| Colorado | no PDP | — | — | — |
| Arizona | no PDP | — | — | — |
| Nevada | no PDP | — | — | — |
| Oregon and Washington | no PDP | — | — | — |
| Idaho and Utah | no PDP | — | — | — |
| Hawaii | no PDP | — | — | — |
| Alaska | no PDP | — | — | — |
| American Samoa | no PDP | — | — | — |
| Guam | no PDP | — | — | — |
| Northern Mariana Islands | no PDP | — | — | — |
| Puerto Rico | no PDP | — | — | — |
| U.S. Virgin Islands | no PDP | — | — | — |
Plan-by-plan detail
Open a region to see every plan that covers this drug, with tier, cost-sharing and restrictions.
Pennsylvania and West Virginia — 2 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible | 2Generic | $5.00 | $12.50 | $0.2003 | — | None |
| Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible | 2Generic | 25% | 25% | $0.2003 | — | None |
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 — elsewhere it depends on what is prescribed.
Michigan — 2 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible | 1Preferred Generic | $1.00 | $3.00 | $0.1560 | $3.7424 units |
|
| Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible | 1Preferred Generic | $1.00 | $2.00 | $0.1560 | $3.7424 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 — elsewhere it depends on what is prescribed.
Kansas — 2 plans, 2 with restrictions
| 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% | $0.5208 | $12.5024 units |
|
| Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible | 3Preferred Brand | 20% | 20% | $0.5208 | $12.5024 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 — elsewhere it depends on what is prescribed.
California — 2 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 49% | 49% | $0.2606 | — | None |
| Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible | 4Non-Preferred Drug | 37% | 37% | $0.2606 | — | None |
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 — elsewhere it depends on what is prescribed.
New Jersey — 1 plan, 1 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible | 3Preferred Brand | 20% | 20% | $0.2297 | $5.5124 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 — elsewhere it depends on what is prescribed.
North Carolina — 1 plan, 1 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible | 3Preferred Brand | $45.00 | $135.00 | $0.2945 | $7.0724 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 — elsewhere it depends on what is prescribed.
South Carolina — 1 plan
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible | 6Select Care Drugs | $5.00 | $12.50 | $0.3002 | — | None |
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 — elsewhere it depends on what is prescribed.
Florida — 1 plan, 1 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible | 6Select Care Drugs | $0.00 | $0.00 | $0.2610 | $6.2624 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 — elsewhere it depends on what is prescribed.
Alabama and Tennessee — 1 plan, 1 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible | 3Preferred Brand | $47.00 | $94.00 | $0.1980 | $4.7524 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 — elsewhere it depends on what is prescribed.
Illinois — 1 plan, 1 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $0.3402 | $8.1624 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 — elsewhere it depends on what is prescribed.
Texas — 1 plan, 1 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $0.3555 | $8.5324 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 — elsewhere it depends on what is prescribed.
Oklahoma — 1 plan, 1 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $0.3355 | $8.0524 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 — elsewhere it depends on what is prescribed.
New Mexico — 1 plan, 1 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible | 3Preferred Brand | 14% | 14% | $0.3010 | $7.2224 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 — elsewhere it depends on what is prescribed.
No stand-alone Part D plan in Maine and New Hampshire
None of the 9 stand-alone Part D plans in CMS PDP Region 01 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Connecticut, Massachusetts, Rhode Island and Vermont
None of the 11 stand-alone Part D plans in CMS PDP Region 02 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in New York
None of the 10 stand-alone Part D plans in CMS PDP Region 03 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Delaware, DC and Maryland
None of the 10 stand-alone Part D plans in CMS PDP Region 05 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Virginia
None of the 9 stand-alone Part D plans in CMS PDP Region 07 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Georgia
None of the 10 stand-alone Part D plans in CMS PDP Region 10 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Ohio
None of the 10 stand-alone Part D plans in CMS PDP Region 14 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Indiana and Kentucky
None of the 10 stand-alone Part D plans in CMS PDP Region 15 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Wisconsin
None of the 10 stand-alone Part D plans in CMS PDP Region 16 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Missouri
None of the 10 stand-alone Part D plans in CMS PDP Region 18 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Arkansas
None of the 12 stand-alone Part D plans in CMS PDP Region 19 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Mississippi
None of the 10 stand-alone Part D plans in CMS PDP Region 20 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Louisiana
None of the 10 stand-alone Part D plans in CMS PDP Region 21 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming
None of the 11 stand-alone Part D plans in CMS PDP Region 25 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Colorado
None of the 10 stand-alone Part D plans in CMS PDP Region 27 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Arizona
None of the 10 stand-alone Part D plans in CMS PDP Region 28 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Nevada
None of the 10 stand-alone Part D plans in CMS PDP Region 29 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Oregon and Washington
None of the 10 stand-alone Part D plans in CMS PDP Region 30 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Idaho and Utah
None of the 10 stand-alone Part D plans in CMS PDP Region 31 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Hawaii
None of the 8 stand-alone Part D plans in CMS PDP Region 33 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Alaska
None of the 9 stand-alone Part D plans in CMS PDP Region 34 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in American Samoa
None of the 1 stand-alone Part D plans in CMS PDP Region 35 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Guam
None of the 1 stand-alone Part D plans in CMS PDP Region 36 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Northern Mariana Islands
None of the 1 stand-alone Part D plans in CMS PDP Region 37 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Puerto Rico
None of the 3 stand-alone Part D plans in CMS PDP Region 38 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in U.S. Virgin Islands
None of the 1 stand-alone Part D plans in CMS PDP Region 39 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.