saxagliptin-metformin er

Generic: saxagliptin HCl/metformin HCl

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

20 plans

Source: PDF · Formulary date: Oct 7, 2026 · Checked: 17 hours, 20 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Connect Silver RD 2200 Indiv Med Deductible	Tier 2 - Generic	—	—	✓	QL
Connect Bronze 7000 HSA Indiv Med Deductible	Tier 2 - Generic	—	—	✓	QL
Connect Gold RD CMS Standard	Tier 2 - Generic	—	—	✓	QL
Connect Bronze 6500 Indiv Med Deductible	Tier 2 - Generic	—	—	✓	QL
Connect Bronze 5500 Indiv Med Deductible	Tier 2 - Generic	—	—	✓	QL
Connect Silver 5000 Indiv Med Deductible	Tier 2 - Generic	—	—	✓	QL
Connect Silver 3600 Indiv Med Deductible	Tier 2 - Generic	—	—	✓	QL
Connect Silver 3000 Indiv Med Deductible	Tier 2 - Generic	—	—	✓	QL
Connect Bronze CMS Standard	Tier 2 - Generic	—	—	✓	QL
Connect Silver CMS Standard	Tier 2 - Generic	—	—	✓	QL
Connect Gold CMS Standard	Tier 2 - Generic	—	—	✓	QL
Connect myDiabetesCare Bronze	Tier 2 - Generic	—	—	✓	QL
Connect myDiabetesCare Silver	Tier 2 - Generic	—	—	✓	QL
Connect Gold 1500 Indiv Med Deductible	Tier 2 - Generic	—	—	✓	QL
Connect Bronze RD 5000 Indiv Med Deductible	Tier 2 - Generic	—	—	✓	QL
Connect Bronze RD 6000 Indiv Med Deductible	Tier 2 - Generic	—	—	✓	QL
Connect Bronze RD CMS Standard	Tier 2 - Generic	—	—	✓	QL
Connect Silver RD 3500 Indiv Med Deductible	Tier 2 - Generic	—	—	✓	QL
Connect Silver RD 5000 Indiv Med Deductible	Tier 2 - Generic	—	—	✓	QL
Connect Silver RD CMS Standard	Tier 2 - Generic	—	—	✓	QL

3 plans

Source: CMS QHP JSON · Formulary date: Sep 16, 2026 · Checked: 17 hours, 20 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Longevity Health Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	✓ 30 per 30 days	QL
Wellcare Giveback Open (PPO)	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Wellcare Dual Reserve (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL

1 plan

Source: Excel (XLSX) · Formulary date: Jul 31, 2026 · Checked: 17 hours, 20 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026 via saxagliptin HCl/metformin HCl	Tier 3 - Non-Formulary	✓	—	—	PA