3 ML insulin degludec 100 UNT/ML / liraglutide 3.6 MG/ML Pen Injector [Xultophy]
insulin degludec
RxCUI: 1860172
What the CMS Formulary Data Shows for 3 ML insulin degludec 100 UNT/ML / liraglutide 3.6 MG/ML Pen Injector [Xultophy]
Per the CMS 2026 Part D formulary file, 3 ML insulin degludec 100 UNT/ML / liraglutide 3.6 MG/ML Pen Injector [Xultophy] (RxNorm concept RXCUI 1860172, generic name insulin degludec) appears on 132 distinct formulary files spanning 1,703 Medicare Part D plan offerings - 33.6% of enrollable Part D products, selective placement; verify formulary inclusion before enrolling. Tier placement ranges from Tier 1 to Tier 6, with a cross-plan average of Tier 2.7.
Real-world access to 3 ML insulin degludec 100 UNT/ML / liraglutide 3.6 MG/ML Pen Injector [Xultophy] depends on utilization management as much as tier placement: 0% of covering formularies require prior authorization. 0.8% require step therapy. 97% apply quantity limits.
Medicare Part D spending dashboard figures are not published for this drug. The plan-by-plan detail below lists exactly which PDP and MA-PD contracts carry 3 ML insulin degludec 100 UNT/ML / liraglutide 3.6 MG/ML Pen Injector [Xultophy] today.
Coverage Details
- Formularies covering
- 132
- Plans covering
- 1,703
- Coverage rate
- 33.6%
- Tier range
- Tier 1 – Tier 6
- Average tier
- Tier 3, Preferred Brand
Restrictions
- Prior authorization required
- 0% of formularies
- Step therapy required
- 0.8% of formularies
- Quantity limits
- 97% of formularies
Tier Distribution Across Plans
Medicare Advantage Plans (MA-PD) Covering 3 ML insulin degludec 100 UNT/ML / liraglutide 3.6 MG/ML Pen Injector [Xultophy]
100 Medicare Advantage plans with Part D drug coverage include this drug.
| Plan | Insurer | Tier | PA | Premium | States |
|---|---|---|---|---|---|
| Florida Complete Care-Duals VIP (HMO-POS D-SNP) | HPMP OF FLORIDA, INC. | T1 | No | $0 | FL |
| Mercy Care Advantage (HMO D-SNP) | MERCY CARE | T1 | No | $0 | AZ |
| Mercy Care Advantage (HMO D-SNP) | MERCY CARE | T1 | No | $0 | AZ |
| Mercy Care Advantage (HMO D-SNP) | MERCY CARE | T1 | No | $0 | AZ |
| Elderplan Plus Long-Term Care (HMO-POS D-SNP) | ELDERPLAN, INC. | T1 | No | $0 | NY |
| Health Choice Pathway (HMO D-SNP) | HEALTH CHOICE ARIZONA, INC. | T1 | No | $0 | AZ |
| Healthfirst CompleteCare (HMO D-SNP) | HEALTHFIRST HEALTH PLAN, INC. | T1 | No | $0 | NY |
| IMCare Classic (HMO D-SNP) | ITASCA MEDICAL CARE | T1 | No | $0 | MN |
| Johns Hopkins Advantage MD D-SNP (HMO D-SNP) | HOPKINS HEALTH ADVANTAGE, INC. | T1 | No | $0 | MD |
| MetroPlus UltraCare (HMO D-SNP) | METROPLUS HEALTH PLAN, INC. | T1 | No | $0 | NY |
| Senior Whole Health SCO (HMO D-SNP) | SENIOR WHOLE HEALTH, LLC | T1 | No | $0 | MA |
| Senior Whole Health SCO NHC (HMO D-SNP) | SENIOR WHOLE HEALTH, LLC | T1 | No | $0 | MA |
| Molina One Care (HMO D-SNP) | SENIOR WHOLE HEALTH, LLC | T1 | No | $0 | MA |
| CCA One Care (HMO D-SNP) | COMMONWEALTH CARE ALLIANCE, INC. | T1 | No | $0 | MA |
| CCA Senior Care Options (HMO D-SNP) | COMMONWEALTH CARE ALLIANCE, INC. | T1 | No | $0 | MA |
| Elevate Medicare Choice (HMO D-SNP) | DENVER HEALTH MEDICAL PLAN, INC. | T1 | No | $0 | CO |
| AllCare Advantage Redwood Rx (HMO D-SNP) | ALLCARE HEALTH PLAN, INC. | T1 | No | $0 | OR |
| PrimeWest Senior Health Complete (HMO D-SNP) | PRIMEWEST RURAL MN HEALTH CARE ACCESS INITIATIVE | T1 | No | $0 | MN |
| Prime Health Complete (HMO D-SNP) | PRIMEWEST RURAL MN HEALTH CARE ACCESS INITIATIVE | T1 | No | $0 | MN |
| Alterwood Advantage Dual Secure (HMO D-SNP) | ALTERWOOD ADVANTAGE, INC. | T1 | No | $0 | MD |
| Nascentia Dual Advantage (HMO D-SNP) | VISITING NURSE ASSOCIATION OF CENTRAL NEW YORK | T1 | No | $0 | NY |
| Abilis Health Community (HMO I-SNP) | SIGNATURE ADVANTAGE, LLC | T1 | No | $0 | KY, TN |
| Arkansas Integrated Providers (AIP) Dual Advantage (HMO D-SNP) | ARKANSAS SUPERIOR SELECT, INC. | T1 | No | $0 | AR |
| Mass General Brigham SCO (HMO D-SNP) | MASS GENERAL BRIGHAM HEALTH PLAN, INC | T1 | No | $0 | MA |
| Mass General Brigham One Care (HMO D-SNP) | MASS GENERAL BRIGHAM HEALTH PLAN, INC | T1 | No | $0 | MA |
| Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | No | $0 | PA |
| Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | No | $0 | PA |
| Highmark Health Options Duals (HMO D-SNP) | HIGHMARK HEALTH OPTIONS WEST VIRGINIA INC. | T1 | No | $0 | WV |
| Highmark Health Options Duals (HMO D-SNP) | HIGHMARK BCBSD, INC. | T1 | No | $0 | DE |
| Florida Complete Care (HMO I-SNP) | HPMP OF FLORIDA, INC. | T1 | No | $4.80 | FL |
| Florida Complete Care- In The Community (HMO-POS I-SNP) | HPMP OF FLORIDA, INC. | T1 | No | $4.80 | FL |
| Gold Dialysis & Kidney Complete (HMO-POS C-SNP) | GOLD KIDNEY OF FLORIDA INC | T1 | No | $4.80 | FL |
| Texas Independence Health Plan, Inc. (HMO I-SNP) | TEXAS INDEPENDENCE HEALTH PLAN, INC. | T1 | No | $4.80 | TX |
| Texas Independence Community Plan (HMO I-SNP) | TEXAS INDEPENDENCE HEALTH PLAN, INC. | T1 | No | $4.80 | TX |
| Tribute Select (HMO-POS I-SNP) | ARKANSAS SUPERIOR SELECT, INC. | T1 | No | $8.90 | AR |
| ATRIO Special Needs Plan (HMO D-SNP) | ATRIO HEALTH PLANS | T1 | No | $10.50 | OR |
| ATRIO Special Needs Plan (HMO D-SNP) | ATRIO HEALTH PLANS | T1 | No | $10.50 | OR |
| Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | No | $13.10 | PA |
| Gold Dialysis & Kidney Complete (HMO-POS C-SNP) | GOLD KIDNEY OF ARIZONA | T1 | No | $17.00 | AZ |
| Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | No | $17.60 | PA |
| Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP) | ELDERPLAN, INC. | T1 | No | $22.70 | NY |
| VIVA Medicare Extra Value (HMO D-SNP) | VIVA HEALTH, INC. | T1 | No | $27.70 | AL |
| VIVA Medicare Extra Care (HMO D-SNP) | VIVA HEALTH, INC. | T1 | No | $27.70 | AL |
| Alterwood Advantage Dual Value (HMO D-SNP) | ALTERWOOD ADVANTAGE, INC. | T1 | No | $31.20 | MD |
| Highmark Health Options Duals Select (HMO D-SNP) | HIGHMARK BCBSD, INC. | T1 | No | $31.20 | DE |
| Valor Health Plan (HMO I-SNP) | TSG GUARD, INC. | T1 | No | $31.40 | OH |
| WV Senior Advantage (HMO I-SNP) | WEST VIRGINIA SENIOR ADVANTAGE, INC. | T1 | No | $32.70 | WV |
| Abilis Health (HMO I-SNP) | SIGNATURE ADVANTAGE, LLC | T1 | No | $35.90 | KY, TN |
| CommuniCare Advantage ISNP (HMO I-SNP) | OH CHS SNP INC. | T1 | No | $38.40 | IN, MD, OH |
| Elderplan Advantage For Nursing Home Residents (HMO-POS I-SNP) | ELDERPLAN, INC. | T1 | No | $44.80 | NY |
Frequently Asked Questions
Is 3 ML insulin degludec 100 UNT/ML / liraglutide 3.6 MG/ML Pen Injector [Xultophy] covered by Medicare Part D?
Yes, 3 ML insulin degludec 100 UNT/ML / liraglutide 3.6 MG/ML Pen Injector [Xultophy] is covered by 1,703 Medicare Part D plans (33.6% of all Part D formularies).
What tier is 3 ML insulin degludec 100 UNT/ML / liraglutide 3.6 MG/ML Pen Injector [Xultophy] on Medicare Part D plans?
3 ML insulin degludec 100 UNT/ML / liraglutide 3.6 MG/ML Pen Injector [Xultophy] averages Tier 2.7 across Part D plans, ranging from Tier 1 to Tier 6.
Does 3 ML insulin degludec 100 UNT/ML / liraglutide 3.6 MG/ML Pen Injector [Xultophy] require prior authorization?
0% of Part D formularies require prior authorization for 3 ML insulin degludec 100 UNT/ML / liraglutide 3.6 MG/ML Pen Injector [Xultophy]. Step therapy: 0.8%. Quantity limits: 97%.
Read our methodology - how this data is sourced, computed, and verified.