Lidocore

4 % — ADHESIVE PATCH, MEDICATED

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

1 plan

Source: Excel (XLSX) · Formulary date: Sep 23, 2026 · Checked: 6 hours, 17 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 2 - Brand Formulary	—	—	✓ LIDODERM PATCH TO BE DISP A MAX QTY OF 90 PATCHES PER DISP AT RTL OR 270 PATCHES AT MAIL	QL Quantity limit