XDEMVY 2.5 mg/mL Solution/ Drops

Also known as Lotilaner Ophthalmic Solution. Coverage in North Carolina (CMS PDP Region 08).

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

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

160 Medicare Advantage plans in NC 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. NC: 160 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)$6.80/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$203.2520	$144.310.71 units	Prior authorization Quantity limit 1 per 42 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$203.2520	$144.310.71 units	Prior authorization Quantity limit 1 per 42 days
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$219.8283	$156.080.71 units	Quantity limit 1 per 42 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$195.5100	$138.810.71 units	Prior authorization Quantity limit 1 per 42 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$195.3100	$138.670.71 units	Prior authorization Quantity limit 1 per 42 days
Humana Premier Rx Plan (PDP)$110.90/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)$119.80/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$219.8283	$156.080.71 units	Quantity limit 1 per 42 days
Wellcare Value Script (PDP)$3.60/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)$4.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$191.9000	$136.250.71 units	Prior authorization Quantity limit 1 per 42 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$207.7730	—	Prior authorization
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$201.5958	$143.130.71 units	Prior authorization Quantity limit 1 per 42 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$207.7730	—	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 →