Arixtra

Generic: Fondaparinux

2.5MG/0.5ML, 5MG/0.4ML, 7.5MG/0.6ML, 10MG/0.8ML — Prefilled Syringe

Anticoagulants — Injectable

Also known as: ARIXTRA SOLN 2.5MG/0.5ML, 5MG/0.4ML, 7.5MG/0.6ML, 10MG/0.8ML ARIXTRA SOLN 2.5MG/0.5ML, 10MG/0.8ML ARIXTRA SOLN 2.5MG/0.5ML, 5MG/0.4ML,
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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: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 18 hours, 20 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Basic Option 2026 Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Standard Option 2026 Tier 3 - Non-Preferred Brand — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 18 hours, 20 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Care 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Advantage 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Local 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Value 2026 Tier 2 - Medium Cost Generic/Brand — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 18 hours, 20 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver CMS Standard
via Fondaparinux 		Tier 5 - Specialty — — ✓ QL
Connect Bronze 5500 Indiv Med Deductible
via Fondaparinux 		Tier 5 - Specialty — — ✓ QL
Connect Bronze RD 6000 Indiv Med Deductible
via Fondaparinux 		Tier 5 - Specialty — — ✓ QL
Connect Silver 3500 Indiv Med Deductible
via Fondaparinux 		Tier 5 - Specialty — — ✓ QL
Connect Bronze RD 5000 Indiv Med Deductible
via Fondaparinux 		Tier 5 - Specialty — — ✓ QL
Connect Silver RD 3500 Indiv Med Deductible
via Fondaparinux 		Tier 5 - Specialty — — ✓ QL
Connect Bronze 7000 HSA Indiv Med Deductible
via Fondaparinux 		Tier 5 - Specialty — — ✓ QL
Connect Silver 4400 Indiv Med Deductible
via Fondaparinux 		Tier 5 - Specialty — — ✓ QL
Connect Silver RD 5000 Indiv Med Deductible
via Fondaparinux 		Tier 5 - Specialty — — ✓ QL
Connect Silver 3000 Indiv Med Deductible
via Fondaparinux 		Tier 5 - Specialty — — ✓ QL
Connect Bronze 6500 Indiv Med Deductible
via Fondaparinux 		Tier 5 - Specialty — — ✓ QL
Connect Bronze RD CMS Standard
via Fondaparinux 		Tier 5 - Specialty — — ✓ QL
Connect Gold CMS Standard
via Fondaparinux 		Tier 5 - Specialty — — ✓ QL
Connect Silver RD CMS Standard
via Fondaparinux 		Tier 5 - Specialty — — ✓ QL
Connect Bronze CMS Standard
via Fondaparinux 		Tier 5 - Specialty — — ✓ QL
Connect Gold RD CMS Standard
via Fondaparinux 		Tier 5 - Specialty — — ✓ QL
Connect myDiabetesCare Silver
via Fondaparinux 		Tier 5 - Specialty — — ✓ QL
Connect Silver RD 2200 Indiv Med Deductible
via Fondaparinux 		Tier 5 - Specialty — — ✓ QL
Connect Gold 1500 Indiv Med Deductible
via Fondaparinux 		Tier 5 - Specialty — — ✓ QL
Connect myDiabetesCare Bronze
via Fondaparinux 		Tier 5 - Specialty — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 18 hours, 20 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Fondaparinux 		Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP)
via Fondaparinux 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Fondaparinux 		Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Fondaparinux 		Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP)
via Fondaparinux 		Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP)
via Fondaparinux 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP)
via Fondaparinux 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Fondaparinux 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage (HMO C-SNP)
via Fondaparinux 		Tier 2 - Generic — — — None
Senior Care (HMO I-SNP)
via Fondaparinux 		Tier 2 - Generic — — — None
Troy Medicare (HMO)
via Fondaparinux 		Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Fondaparinux 		Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Fondaparinux 		Tier 2 - Generic — — — None
Aetna Medicare Signature (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Extra (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Giveback (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
HealthSpring True Choice (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare (HMO D-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred (HMO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Select (HMO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Savings (HMO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Plus (HMO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
DEVOTED DUAL 009 NC (HMO D-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
DEVOTED CORE 001 NC (HMO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
DEVOTED GIVEBACK 002 NC (HMO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
DEVOTED GIVEBACK 012 NC (HMO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 001 NC (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 003 NC (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 005 NC (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Alignment Health Platinum (HMO)
via Fondaparinux 		Tier 4 - Non-Preferred — — ✓ 15 per 90 days QL
Alignment Health NC Duals (HMO-POS D-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — ✓ 15 per 90 days QL
Alignment Health smartHMO (HMO)
via Fondaparinux 		Tier 4 - Non-Preferred — — ✓ 15 per 90 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — ✓ 15 per 90 days QL
Alignment Health Platinum Select (HMO)
via Fondaparinux 		Tier 4 - Non-Preferred — — ✓ 15 per 90 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — ✓ 15 per 90 days QL
Alignment Health AVA (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — ✓ 15 per 90 days QL
HealthTeam Advantage Plan I (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan II (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Vitality Plan (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 008 NC (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S001 (PPO D-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S2 (PPO D-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Erickson Advantage Signature (HMO-POS)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Erickson Advantage Guardian (HMO-POS I-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Erickson Advantage Freedom (HMO-POS)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Erickson Advantage Liberty (HMO-POS)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Erickson Advantage Champion (HMO-POS C-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Dual (HMO D-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Value Plus (HMO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Prime (HMO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Care (HMO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (HMO)
via Fondaparinux 		Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 18 hours, 20 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026
via Fondaparinux 		Non-Preferred — — — None
NC Medicaid Preferred Drug List 2026 Non-Preferred — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 18 hours, 20 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026 Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 70/30 Standard PPO 2026 Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 80/20 Plus PPO 2026 Tier 3 - Non-Preferred Brand — — — None
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