LIDOCAN III 50 mg/g Patch
Also known as Lidocaine 5%. Coverage in Oklahoma (CMS PDP Region 23).
4 of 11 stand-alone Part D plans in Oklahoma cover this drug on tier 3–4.
4 of 4 plans apply a prior authorization, step therapy or quantity limit.
29 Medicare Advantage plans in OK 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. OK: 29 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)$5.60/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $4.0347 | $36.319 units |
|
| Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 40% | 40% | $2.5515 | $22.969 units |
|
| Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 26% | 26% | $4.0549 | $36.499 units |
|
| Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 32% | 32% | $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.