Xiidra

Generic: lifitegrast

50 MG — Drops

Anti-Inflammatory / Immunomodulator

Also known as: lifitegrast XIIDRA SOLN 5% Xiidra Ophthalmic Solution
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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Checked: 17 hours, 3 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Essential + No Referrals Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Bronze Essential + No Referrals Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Bronze Signature + No Referrals Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Signature + No Referrals Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Gold Premier + No Referrals Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Gold Signature + No Referrals Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Bronze Premier + No Referrals Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 17 hours, 3 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Standard Option 2026 Tier 2 - Preferred Brand ✓ — — PA
BCBS Federal Basic Option 2026 Tier 2 - Preferred Brand ✓ — — PA
BCBS Federal Focus 2026 Tier 2 - Preferred Brand ✓ — — PA
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 17 hours, 3 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Bronze RD 5000 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Silver 3500 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect myDiabetesCare Bronze Tier 3 - Preferred Brand — — — None
Connect Gold 1500 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect myDiabetesCare Silver Tier 3 - Preferred Brand — — — None
Connect Bronze RD 6000 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Bronze CMS Standard Tier 3 - Preferred Brand — — — None
Connect Gold RD CMS Standard Tier 3 - Preferred Brand — — — None
Connect Bronze RD CMS Standard Tier 3 - Preferred Brand — — — None
Connect Gold CMS Standard Tier 3 - Preferred Brand — — — None
Connect Silver RD CMS Standard Tier 3 - Preferred Brand — — — None
Connect Silver CMS Standard Tier 3 - Preferred Brand — — — None
Connect Bronze 6500 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Silver 3000 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Silver RD 5000 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Silver 4400 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Bronze 7000 HSA Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Connect Silver RD 3500 Indiv Med Deductible Tier 3 - Preferred Brand — — — None
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 17 hours, 3 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Aetna Medicare Dual (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Aetna Medicare Signature (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Aetna Medicare Value Plus (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Aetna Medicare Prime (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Aetna Medicare Signature Care (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Aetna Medicare Enhanced (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Aetna Medicare Signature (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Aetna Medicare Signature Extra (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Aetna Medicare Signature (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Aetna Medicare Signature (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Aetna Medicare Signature Giveback (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Aetna Medicare Signature (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring True Choice (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring TotalCare (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring TotalCare Plus (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring Preferred (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring Preferred Select (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring Preferred Savings (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
HealthSpring Preferred Plus (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 3 - Preferred Brand — — — None
DEVOTED CORE 001 NC (HMO) Tier 3 - Preferred Brand — — — None
DEVOTED GIVEBACK 002 NC (HMO) Tier 3 - Preferred Brand — — — None
DEVOTED GIVEBACK 012 NC (HMO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 001 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 003 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 005 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE 008 NC (PPO) Tier 3 - Preferred Brand — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 3 - Preferred Brand — — — None
Liberty Medicare Advantage (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Blue Medicare PPO Enhanced (PPO) Tier 3 - Preferred Brand ✓ — ✓ 60 per 30 days PA | QL
Blue Medicare Essential Plus (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 60 per 30 days PA | QL
Blue Medicare Enhanced (HMO-POS) Tier 3 - Preferred Brand ✓ — ✓ 60 per 30 days PA | QL
Blue Medicare Choice (HMO) Tier 3 - Preferred Brand ✓ — ✓ 60 per 30 days PA | QL
Blue Medicare Essential (HMO) Tier 3 - Preferred Brand ✓ — ✓ 60 per 30 days PA | QL
Experience Health Medicare Advantage (HMO) Tier 3 - Preferred Brand ✓ — ✓ 60 per 30 days PA | QL
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 3 - Preferred Brand ✓ — ✓ 60 per 30 days PA | QL
Alignment Health Platinum (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Alignment Health smartHMO (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Alignment Health Platinum Select (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Alignment Health AVA (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Senior Care (HMO I-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
HealthTeam Advantage Plan I (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
HealthTeam Advantage Plan II (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
HealthTeam Advantage Vitality Plan (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Erickson Advantage Champion (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Erickson Advantage Liberty (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Erickson Advantage Freedom (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Erickson Advantage Signature (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 17 hours, 3 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026 Preferred — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 17 hours, 3 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 80/20 Plus PPO 2026 Tier 2 - Non-Preferred Generic ✓ — — PA
NC State Health Plan - 70/30 Standard PPO 2026 Tier 2 - Non-Preferred Generic ✓ — — PA
NC State Health Plan - HDHP 2026 Tier 2 - Non-Preferred Generic ✓ — — PA
Source: CMS QHP JSON  ·  Checked: 17 hours, 3 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Silver Classic Standard | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Classic Standard | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Gold Classic Standard Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Simple Diabetes | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Simple PCP Saver | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Gold Elite Saver Plus | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Simple Chronic Care CKM | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Simple Diabetes | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Simple Chronic Care CKM | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
AIAN Cost Share Tier 3 - Preferred Brand ✓ — ✓ PA | QL
AIAN Cost Share | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Classic Standard Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Classic Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Secure Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Classic 4700 Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Simple PCP Saver Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Gold Elite Saver Plus Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Simple Diabetes Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Secure | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Classic 4700 | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Classic Standard Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Silver Classic | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
Gold Classic Standard | with Atrium Health Tier 3 - Preferred Brand ✓ — ✓ PA | QL
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