Allevyn Ag
Miscellaneous
Also known as:
ALLEVYN AG MIS 6-3/4"
ALLEVYN AG MIS 9"X9"SAC
ALLEVYN AG PAD 2"X2"
ALLEVYN AG PAD 3"X3"
ALLEVYN AG PAD 4"X4"
ALLEVYN AG PAD 5"X5"
ALLEVYN AG PAD 6"X6"
ALLEVYN AG PAD 7"X7"
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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.
NC State Health Plan
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| NC State Health Plan - 80/20 Plus PPO 2026 | Tier 3 - Non-Preferred Brand | ✓ | — | — | PA |
| NC State Health Plan - 70/30 Standard PPO 2026 | Tier 3 - Non-Preferred Brand | ✓ | — | — | PA |
| NC State Health Plan - HDHP 2026 | Tier 3 - Non-Preferred Brand | ✓ | — | — | PA |