LIDOCAN III 50 mg/g Patch (Lidocaine 5%) — Medicare Part D coverage and cost

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
Kansas	6 of 12	3–4	—	6 of 6 plans
Connecticut, Massachusetts, Rhode Island and Vermont	5 of 11	3–4	—	5 of 5 plans
New Jersey	5 of 12	3–4	—	5 of 5 plans
North Carolina	5 of 12	3–4	—	5 of 5 plans
Florida	5 of 10	3–4	—	5 of 5 plans
Alabama and Tennessee	5 of 12	3–4	—	5 of 5 plans
Illinois	5 of 12	3–4	—	5 of 5 plans
Arkansas	5 of 12	3–4	—	5 of 5 plans
Texas	5 of 12	3–4	—	5 of 5 plans
New Mexico	5 of 11	3–4	—	5 of 5 plans
California	5 of 12	3–4	—	5 of 5 plans
Oklahoma	4 of 11	3–4	—	4 of 4 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	4 of 11	3–4	—	4 of 4 plans
Maine and New Hampshire	3 of 9	3–4	—	3 of 3 plans
New York	3 of 10	3–4	—	3 of 3 plans
Delaware, DC and Maryland	3 of 10	3–4	—	3 of 3 plans
Pennsylvania and West Virginia	3 of 12	3–4	—	3 of 3 plans
Virginia	3 of 9	3–4	—	3 of 3 plans
South Carolina	3 of 11	3–4	—	3 of 3 plans
Georgia	3 of 10	3–4	—	3 of 3 plans
Michigan	3 of 12	3–4	—	3 of 3 plans
Ohio	3 of 10	3–4	—	3 of 3 plans
Indiana and Kentucky	3 of 10	3–4	—	3 of 3 plans
Wisconsin	3 of 10	3–4	—	3 of 3 plans
Missouri	3 of 10	3–4	—	3 of 3 plans
Mississippi	3 of 10	3–4	—	3 of 3 plans
Louisiana	3 of 10	3–4	—	3 of 3 plans
Colorado	3 of 10	3–4	—	3 of 3 plans
Arizona	3 of 10	3–4	—	3 of 3 plans
Nevada	3 of 10	3–4	—	3 of 3 plans
Oregon and Washington	3 of 10	3–4	—	3 of 3 plans
Idaho and Utah	3 of 10	3–4	—	3 of 3 plans
Hawaii	3 of 8	3–4	—	3 of 3 plans
Alaska	3 of 9	3–4	—	3 of 3 plans
American Samoa	no PDP	—	—	—
Guam	no PDP	—	—	—
Northern Mariana Islands	no PDP	—	—	—
Puerto Rico	no PDP	—	—	—
U.S. Virgin Islands	no PDP	—	—	—

Kansas — 6 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.0347	$36.319 units	Prior authorization Quantity limit 9 per 30 days
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$7.0638	$63.579 units	Prior authorization Quantity limit 9 per 30 days
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$6.9610	$62.659 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$4.0549	$36.499 units	Prior authorization Quantity limit 9 per 30 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	4Non-Preferred Drug	40%	40%	$6.9610	$62.659 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$5.1760	$46.589 units	Prior authorization Quantity limit 9 per 30 days

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.

Connecticut, Massachusetts, Rhode Island and Vermont — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$2.4300	$21.879 units	Prior authorization Quantity limit 9 per 30 days
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$1.1330	$101.9790 units	Prior authorization Quantity limit 3 per 1 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$2.4300	$21.879 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1.7264	$15.549 units	Prior authorization Quantity limit 9 per 30 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	4Non-Preferred Drug	35%	35%	$1.1330	$101.9790 units	Prior authorization Quantity limit 3 per 1 days

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 — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$2.4300	$21.879 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$2.4300	$21.879 units	Prior authorization Quantity limit 9 per 30 days
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	4Non-Preferred Drug	45%	45%	$2.5515	$22.969 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$2.0717	$18.659 units	Prior authorization Quantity limit 9 per 30 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	4Non-Preferred Drug	45%	45%	$2.5515	$22.969 units	Prior authorization Quantity limit 9 per 30 days

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 — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.0347	$36.319 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$4.0549	$36.499 units	Prior authorization Quantity limit 9 per 30 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$4.9528	$44.589 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$5.1760	$46.589 units	Prior authorization Quantity limit 9 per 30 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	4Non-Preferred Drug	40%	40%	$4.9528	$44.589 units	Prior authorization Quantity limit 9 per 30 days

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 — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$2.4300	$21.879 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$2.4300	$21.879 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.6694	$15.029 units	Prior authorization Quantity limit 9 per 30 days
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$2.5515	$22.969 units	Prior authorization Quantity limit 9 per 30 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$2.5515	$22.969 units	Prior authorization Quantity limit 9 per 30 days

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 — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$2.4300	$21.879 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$2.4300	$21.879 units	Prior authorization Quantity limit 9 per 30 days
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	41%	$6.6150	$59.549 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.6694	$15.029 units	Prior authorization Quantity limit 9 per 30 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	4Non-Preferred Drug	42%	42%	$6.6150	$59.549 units	Prior authorization Quantity limit 9 per 30 days

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 — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.0347	$36.319 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$4.0549	$36.499 units	Prior authorization Quantity limit 9 per 30 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	4Non-Preferred Drug	43%	43%	$4.7540	$42.799 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$5.1760	$46.589 units	Prior authorization Quantity limit 9 per 30 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$4.8030	$43.239 units	Prior authorization Quantity limit 9 per 30 days

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.

Arkansas — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.0347	$36.319 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$4.0549	$36.499 units	Prior authorization Quantity limit 9 per 30 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	34%	$4.7264	$425.3890 units	Prior authorization Quantity limit 3 per 1 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$5.1972	$46.779 units	Prior authorization Quantity limit 9 per 30 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	4Non-Preferred Drug	34%	34%	$4.7264	$425.3890 units	Prior authorization Quantity limit 3 per 1 days

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 — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$2.4300	$21.879 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$2.4300	$21.879 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.4800	$13.329 units	Prior authorization Quantity limit 9 per 30 days
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	42%	$7.0350	$63.319 units	Prior authorization Quantity limit 9 per 30 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$4.4520	$40.079 units	Prior authorization Quantity limit 9 per 30 days

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 — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.0347	$36.319 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$4.0549	$36.499 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$5.1760	$46.589 units	Prior authorization Quantity limit 9 per 30 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.8030	$43.239 units	Prior authorization Quantity limit 9 per 30 days
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$4.7776	$43.009 units	Prior authorization Quantity limit 9 per 30 days

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 — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$2.5901	$23.319 units	Prior authorization Quantity limit 9 per 30 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	3Preferred Brand	19%	19%	$3.4700	$312.3090 units	Prior authorization Quantity limit 3 per 1 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$2.5901	$23.319 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$2.0116	$18.109 units	Prior authorization Quantity limit 9 per 30 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	4Non-Preferred Drug	49%	49%	$3.4700	$312.3090 units	Prior authorization Quantity limit 3 per 1 days

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 — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.0347	$36.319 units	Prior authorization Quantity limit 9 per 30 days
Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$2.5515	$22.969 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$4.0549	$36.499 units	Prior authorization Quantity limit 9 per 30 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$2.5515	$22.969 units	Prior authorization Quantity limit 9 per 30 days

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.

Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming — 4 plans, 4 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$2.4300	$21.879 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$2.4300	$21.879 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$2.0717	$18.659 units	Prior authorization Quantity limit 9 per 30 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	42%	$2.5515	$22.969 units	Prior authorization Quantity limit 9 per 30 days

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.

Maine and New Hampshire — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.0347	$36.319 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$4.0549	$36.499 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$5.1760	$46.589 units	Prior authorization Quantity limit 9 per 30 days

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 York — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$2.4300	$21.879 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$2.4300	$21.879 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$1.9766	$17.799 units	Prior authorization Quantity limit 9 per 30 days

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.

Delaware, DC and Maryland — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.0347	$36.319 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$4.0549	$36.499 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$5.1760	$46.589 units	Prior authorization Quantity limit 9 per 30 days

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.

Pennsylvania and West Virginia — 3 plans, 3 with restrictions

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%	$2.4300	$21.879 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$2.4300	$21.879 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$2.0717	$18.659 units	Prior authorization Quantity limit 9 per 30 days

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.

Virginia — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.0347	$36.319 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$4.0549	$36.499 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$5.1760	$46.589 units	Prior authorization Quantity limit 9 per 30 days

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 — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$4.80/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.0347	$36.319 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$4.0549	$36.499 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$5.1760	$46.589 units	Prior authorization Quantity limit 9 per 30 days

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.

Georgia — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.0347	$36.319 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$4.0549	$36.499 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$5.1760	$46.589 units	Prior authorization Quantity limit 9 per 30 days

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 — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$2.4300	$21.879 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$2.4300	$21.879 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$2.0717	$18.659 units	Prior authorization Quantity limit 9 per 30 days

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.

Ohio — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.0347	$36.319 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$4.0549	$36.499 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$5.1760	$46.589 units	Prior authorization Quantity limit 9 per 30 days

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.

Indiana and Kentucky — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.0347	$36.319 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$4.0549	$36.499 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$5.1556	$46.409 units	Prior authorization Quantity limit 9 per 30 days

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.

Wisconsin — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$2.4300	$21.879 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$2.4300	$21.879 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$2.1932	$19.749 units	Prior authorization Quantity limit 9 per 30 days

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.

Missouri — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.0347	$36.319 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$4.0549	$36.499 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$5.1760	$46.589 units	Prior authorization Quantity limit 9 per 30 days

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.

Mississippi — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.0347	$36.319 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$4.0549	$36.499 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$5.1760	$46.589 units	Prior authorization Quantity limit 9 per 30 days

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.

Louisiana — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$2.4300	$21.879 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$2.4300	$21.879 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$1.6829	$15.159 units	Prior authorization Quantity limit 9 per 30 days

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.

Colorado — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.0347	$36.319 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$4.0549	$36.499 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$5.1760	$46.589 units	Prior authorization Quantity limit 9 per 30 days

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.

Arizona — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.0347	$36.319 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$4.0549	$36.499 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$5.1760	$46.589 units	Prior authorization Quantity limit 9 per 30 days

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.

Nevada — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.0347	$36.319 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$4.0549	$36.499 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$5.1760	$46.589 units	Prior authorization Quantity limit 9 per 30 days

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.

Oregon and Washington — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.0347	$36.319 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$4.0549	$36.499 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$5.1760	$46.589 units	Prior authorization Quantity limit 9 per 30 days

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.

Idaho and Utah — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.0347	$36.319 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$4.0549	$36.499 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$5.1556	$46.409 units	Prior authorization Quantity limit 9 per 30 days

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.

Hawaii — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.0347	$36.319 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$5.1556	$46.409 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$4.0549	$36.499 units	Prior authorization Quantity limit 9 per 30 days

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.

Alaska — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.0347	$36.319 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$4.0549	$36.499 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$5.1760	$46.589 units	Prior authorization Quantity limit 9 per 30 days

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.

LIDOCAN III 50 mg/g Patch

Coverage by region

Plan-by-plan detail

No stand-alone Part D plan in American Samoa

No stand-alone Part D plan in Guam

No stand-alone Part D plan in Northern Mariana Islands

No stand-alone Part D plan in Puerto Rico

No stand-alone Part D plan in U.S. Virgin Islands