XDEMVY 2.5 mg/mL Solution/ Drops

Also known as Lotilaner Ophthalmic Solution. Coverage in Indiana and Kentucky (CMS PDP Region 15).

10 of 10 stand-alone Part D plans in Indiana and Kentucky cover this drug on tier 4–5.

10 of 10 plans apply a prior authorization, step therapy or quantity limit.

219 Medicare Advantage plans in IN, KY 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. IN: 116 plans · KY: 103 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$203.2378	$144.300.71 units	Prior authorization Quantity limit 1 per 42 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$203.2378	$144.300.71 units	Prior authorization Quantity limit 1 per 42 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$195.5100	$138.810.71 units	Prior authorization Quantity limit 1 per 42 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	—	$220.2692	$156.390.71 units	Quantity limit 1 per 42 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$195.3100	$138.670.71 units	Prior authorization Quantity limit 1 per 42 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$203.2378	$144.300.71 units	Prior authorization Quantity limit 1 per 42 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$220.2692	$156.390.71 units	Quantity limit 1 per 42 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$191.9000	$136.250.71 units	Prior authorization Quantity limit 1 per 42 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$191.9000	$136.250.71 units	Prior authorization Quantity limit 1 per 42 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$201.5928	$143.130.71 units	Prior authorization Quantity limit 1 per 42 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.

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