No prior authorization
Does Molina Healthcare require prior authorization for Xigduo?
Molina Healthcare does not require prior authorization for Xigduo on the Medicare Part D plans that cover it.
No covering plan from this payer files a prior-authorization requirement for this drug.
- This drug does not appear on any of this payer's Medicare Part D formularies. That means it is NOT COVERED under those plans — which is a different and generally worse outcome than requiring prior authorization. An exception or formulary-exception request may still be possible.
By product strength
| RxNorm product | Plans covering | Require prior auth | Step therapy | Qty limit | Status |
|---|---|---|---|---|---|
| 24 HR dapagliflozin 10 MG / metformin hydrochloride 1000 MG Extended Release Oral Tablet [Xigduo]1593775 | 51 / 51 | 0 | 0 | 51 | No prior authorization |
| 24 HR dapagliflozin 5 MG / metformin hydrochloride 500 MG Extended Release Oral Tablet [Xigduo]1593831 | 51 / 51 | 0 | 0 | 51 | No prior authorization |
| 24 HR dapagliflozin 5 MG / metformin hydrochloride 1000 MG Extended Release Oral Tablet [Xigduo]1593833 | 51 / 51 | 0 | 0 | 51 | No prior authorization |
| 24 HR dapagliflozin 10 MG / metformin hydrochloride 500 MG Extended Release Oral Tablet [Xigduo]1593835 | 0 / 51 | 0 | 0 | 0 | Not on formulary |
| 24 HR dapagliflozin 2.5 MG / metformin hydrochloride 1000 MG Extended Release Oral Tablet [Xigduo]1940498 | 0 / 51 | 0 | 0 | 0 | Not on formulary |
Product names come from RxNorm (U.S. National Library of Medicine).
Plan-by-plan detail — 24 HR dapagliflozin 10 MG / metformin hydrochloride 1000 MG Extended Release Oral Tablet [Xigduo]
Xigduo has 5 products in the corpus; this table is for 24 HR dapagliflozin 10 MG / metformin hydrochloride 1000 MG Extended Release Oral Tablet [Xigduo], the one carried on the most plans. The product table above covers every strength.
| Plan | Contract | Tier | Prior auth | Step therapy | Qty limit |
|---|---|---|---|---|---|
| Molina Complete Care for MyCare Ohio (HMO D-SNP) | H9955-008 | 3 | No | No | Yes |
| Molina Dual MI Coordinated Health (HMO D-SNP) | H5926-008 | 3 | No | No | Yes |
| Molina Dual MI Coordinated Health (HMO D-SNP) | H5926-009 | 3 | No | No | Yes |
| Molina Medicare Choice Care (HMO) | H2715-003 | 3 | No | No | Yes |
| Molina Medicare Choice Care (HMO) | H5810-014 | 3 | No | No | Yes |
| Molina Medicare Complete Care (HMO D-SNP) | H1799-004 | 3 | No | No | Yes |
| Molina Medicare Complete Care (HMO D-SNP) | H1799-005 | 3 | No | No | Yes |
| Molina Medicare Complete Care (HMO D-SNP) | H2478-001 | 3 | No | No | Yes |
| Molina Medicare Complete Care (HMO D-SNP) | H2715-006 | 3 | No | No | Yes |
| Molina Medicare Complete Care (HMO D-SNP) | H2715-006 | 3 | No | No | Yes |
| Molina Medicare Complete Care (HMO D-SNP) | H5628-001 | 3 | No | No | Yes |
| Molina Medicare Complete Care (HMO D-SNP) | H5628-013 | 3 | No | No | Yes |
| Molina Medicare Complete Care (HMO D-SNP) | H5628-013 | 3 | No | No | Yes |
| Molina Medicare Complete Care (HMO D-SNP) | H5823-013 | 3 | No | No | Yes |
| Molina Medicare Complete Care (HMO D-SNP) | H5823-013 | 3 | No | No | Yes |
| Molina Medicare Complete Care (HMO D-SNP) | H5926-001 | 3 | No | No | Yes |
| Molina Medicare Complete Care (HMO D-SNP) | H7678-006 | 3 | No | No | Yes |
| Molina Medicare Complete Care (HMO D-SNP) | H7678-006 | 3 | No | No | Yes |
| Molina Medicare Complete Care (HMO D-SNP) | H8845-001 | 3 | No | No | Yes |
| Molina Medicare Complete Care (HMO D-SNP) | H8845-004 | 3 | No | No | Yes |
| Molina Medicare Complete Care (HMO D-SNP) | H8845-005 | 3 | No | No | Yes |
| Molina Medicare Complete Care (HMO D-SNP) | H8845-007 | 3 | No | No | Yes |
| Molina Medicare Complete Care (HMO D-SNP) | H8845-007 | 3 | No | No | Yes |
| Molina Medicare Complete Care (HMO D-SNP) | H9955-007 | 3 | No | No | Yes |
| Molina Medicare Complete Care Plus (HMO D-SNP) | H3038-004 | 3 | No | No | Yes |
| Molina Medicare Complete Care Plus (HMO D-SNP) | H3038-004 | 3 | No | No | Yes |
| Molina Medicare Complete Care Plus (HMO D-SNP) | H3038-004 | 3 | No | No | Yes |
| Molina Medicare Complete Care Plus (HMO D-SNP) | H3038-004 | 3 | No | No | Yes |
| Molina Medicare Complete Care Plus (HMO D-SNP) | H3093-001 | 3 | No | No | Yes |
| Molina Medicare Complete Care Plus (HMO D-SNP) | H3093-002 | 3 | No | No | Yes |
| Molina Medicare Complete Care Plus (HMO D-SNP) | H3093-003 | 3 | No | No | Yes |
| Molina Medicare Complete Care Plus (HMO D-SNP) | H3093-004 | 3 | No | No | Yes |
| Molina Medicare Complete Care Plus (HMO D-SNP) | H3093-005 | 3 | No | No | Yes |
| Molina Medicare Complete Care Plus (HMO D-SNP) | H6515-001 | 3 | No | No | Yes |
| Molina Medicare Complete Care Plus (HMO D-SNP) | H6515-002 | 3 | No | No | Yes |
| Molina Medicare Complete Care Plus (HMO D-SNP) | H6515-003 | 3 | No | No | Yes |
| Molina Medicare Complete Care Plus (HMO D-SNP) | H6515-004 | 3 | No | No | Yes |
| Molina Medicare Complete Care Plus (HMO D-SNP) | H6515-005 | 3 | No | No | Yes |
| Molina Medicare Complete Care Plus (HMO D-SNP) | H8176-004 | 3 | No | No | Yes |
| Molina Medicare Complete Care Plus (HMO D-SNP) | H8176-004 | 3 | No | No | Yes |
| Molina Medicare Complete Care Select (HMO D-SNP) | H5628-012 | 3 | No | No | Yes |
| Molina Medicare Complete Care Select (HMO D-SNP) | H5628-014 | 3 | No | No | Yes |
| Molina Medicare Complete Care Select (HMO D-SNP) | H5628-014 | 3 | No | No | Yes |
| Molina Medicare Complete Care Select (HMO D-SNP) | H5823-010 | 3 | No | No | Yes |
| My Choice Wisconsin Medicare Dual Advantage Plan (HMO D-SNP) | H5209-006 | 3 | No | No | Yes |
| My Choice Wisconsin Medicare Dual Advantage Plan (HMO D-SNP) | H5209-006 | 3 | No | No | Yes |
| My Choice Wisconsin Partnership Plan (HMO D-SNP) | H5209-005 | 3 | No | No | Yes |
| My Choice Wisconsin Partnership Plan (HMO D-SNP) | H5209-005 | 3 | No | No | Yes |
| Passport Advantage (HMO D-SNP) | H1799-003 | 3 | No | No | Yes |
| Passport Advantage (HMO D-SNP) | H1799-003 | 3 | No | No | Yes |
| Passport Advantage (HMO D-SNP) | H1799-003 | 3 | No | No | Yes |
Source
Monthly Prescription Drug Plan Formulary and Pharmacy Network Information — Basic Drugs Formulary File- Effective
- 2026-06-30
- Retrieved
- 2026-07-19
- SHA-256
- e626e6bcda1aa6a0071e6f0df6bafe686ae41842cdf0a9feffdc649b6d3ff3ae
We publish the hash of the exact file we ingested so any answer can be audited against the bytes CMS served that day.
Xigduo at other payers
Administrative information only. Benefily reports what a payer has published in its own prior-authorization policy as of the effective date shown. It is not medical advice, not a coverage or payment guarantee, and not an authorization. Requirements vary by plan, place of service and member benefits — always verify with the payer before rendering service.