Find Xiidra formulary coverage for your area

Use the field below to look up your patient’s formulary coverage for Xiidra.

COVERAGE IINFO:

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Check health plan coverage and patient costs, as they may vary or change without notice.

*Based on number of lives covered.

†Covered at any tier; additional restrictions may apply for certain plans.

For informational purposes only. Not all payers or plans may be included.

Formulary Coverage Key1

Tier 1: These drugs are available at the lowest co-pay. Most commonly, these are generic drugs.

Tier 2: These drugs are available at a middle-level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.

Tier 3: These drugs are available at a higher-level co-pay. Most commonly, these are "non-preferred" brand drugs.

Tier 4: These drugs are available at a higher-level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.

Tier >4: These drugs are available at a higher-level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.

ST: Step Therapy. This restriction typically requires that certain criteria be met prior to approval for the prescription.

QL: Quantity Limit. Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of drug that will be covered.

N/A: Not Available. Formulary data for this drug/health plan are not available.

NC: Not Covered. Drugs that are not covered by the plan.

OR: Other Restrictions. Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.

PA: Prior Authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.

Reference

  1. Centers for Medicare & Medicaid Services. How Medicare Prescription Drug Plans & Medicare Advantage Plans with Prescription Drug Coverage (MA-PDs) Use Pharmacies, Formularies, & Common Coverage Rules. October 2015.

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Check health plan coverage and patient costs, as they may vary or change without notice.

For informational purposes only.