XDEMVY 2.5 mg/mL Solution/ Drops

Also known as Lotilaner Ophthalmic Solution. Coverage in Arkansas (CMS PDP Region 19).

12 of 12 stand-alone Part D plans in Arkansas cover this drug on tier 4–5.

12 of 12 plans apply a prior authorization, step therapy or quantity limit.

77 Medicare Advantage plans in AR 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. AR: 77 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$195.3100	$138.670.71 units	Prior authorization Quantity limit 1 per 42 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$203.2520	$144.310.71 units	Prior authorization Quantity limit 1 per 42 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$203.2520	$144.310.71 units	Prior authorization Quantity limit 1 per 42 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$195.5100	$138.810.71 units	Prior authorization Quantity limit 1 per 42 days
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$220.2590	$156.380.71 units	Quantity limit 1 per 42 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$203.2520	$144.310.71 units	Prior authorization Quantity limit 1 per 42 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	4Non-Preferred Drug	29%	—	$220.2590	$156.380.71 units	Quantity limit 1 per 42 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$191.9000	$136.250.71 units	Prior authorization Quantity limit 1 per 42 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$191.9000	$136.250.71 units	Prior authorization Quantity limit 1 per 42 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$201.3440	—	Prior authorization
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$201.5928	$143.130.71 units	Prior authorization Quantity limit 1 per 42 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$201.3440	—	Prior authorization

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 →