LIDOCAN III 50 mg/g Patch
Also known as Lidocaine 5%. Coverage in Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming (CMS PDP Region 25).
4 of 11 stand-alone Part D plans in Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming cover this drug on tier 3–4.
4 of 4 plans apply a prior authorization, step therapy or quantity limit.
118 Medicare Advantage plans in IA, MN, MT, NE, ND, SD 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. IA: 24 plans · MN: 39 plans · MT: 5 plans · NE: 27 plans · ND: 10 plans · SD: 13 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)$9.60/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $2.4300 | $21.879 units |
|
| Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 27% | 27% | $2.4300 | $21.879 units |
|
| SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 35% | 35% | $2.0717 | $18.659 units |
|
| MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 42% | 42% | $2.5515 | $22.969 units |
|
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.