PILOCARPINE HYDROCHLORIDE OPHTHALMIC 12.5 mg/mL Solution/ Drops
Also known as Pilocarpine Hydrochloride. Coverage in Idaho and Utah (CMS PDP Region 31).
2 of 10 stand-alone Part D plans in Idaho and Utah cover this drug on tier 3.
No plan applies a prior authorization, step therapy or quantity limit.
2 Medicare Advantage plans in UT 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. UT: 2 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $18.4690 | — | None |
| HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible | 3Preferred Brand | 21% | 21% | $18.5727 | — | None |
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.