LIDOCAN III 50 mg/g Patch

Also known as Lidocaine 5%. Coverage in Connecticut, Massachusetts, Rhode Island and Vermont (CMS PDP Region 02).

5 of 11 stand-alone Part D plans in Connecticut, Massachusetts, Rhode Island and Vermont cover this drug on tier 3–4.

5 of 5 plans apply a prior authorization, step therapy or quantity limit.

62 Medicare Advantage plans in CT, MA, RI do cover it

Medicare Advantage plans carry their own formularies, separate from stand-alone Part D. A patient on an MA-PD plan may have coverage even where no PDP lists the drug. CT: 21 plans · MA: 31 plans · RI: 10 plans.

Every plan that covers it

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.

See coverage in all 39 regions →