ASA-BUTALB-CAFF-COD #3

Capsule

Platelet Aggregation Inhibitor

Also known as: ASA-BUTALB-CAFF-COD #3 CAPSULE
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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: Oct 15, 2026  ·  Checked: 12 hours, 31 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Bronze RD 5000 Indiv Med Deductible Tier 3 - Preferred Brand ✓ — — PA
Connect Silver 3000 Indiv Med Deductible Tier 3 - Preferred Brand ✓ — — PA
Connect Silver CMS Standard Tier 3 - Preferred Brand ✓ — — PA
Connect myDiabetesCare Silver Tier 3 - Preferred Brand ✓ — — PA
Connect Silver 3600 Indiv Med Deductible Tier 3 - Preferred Brand ✓ — — PA
Connect Bronze CMS Standard Tier 3 - Preferred Brand ✓ — — PA
Connect Gold CMS Standard Tier 3 - Preferred Brand ✓ — — PA
Connect Bronze RD 6000 Indiv Med Deductible Tier 3 - Preferred Brand ✓ — — PA
Connect Bronze RD CMS Standard Tier 3 - Preferred Brand ✓ — — PA
Connect Silver RD 3500 Indiv Med Deductible Tier 3 - Preferred Brand ✓ — — PA
Connect Silver RD 5000 Indiv Med Deductible Tier 3 - Preferred Brand ✓ — — PA
Connect Silver RD CMS Standard Tier 3 - Preferred Brand ✓ — — PA
Connect Silver RD 2200 Indiv Med Deductible Tier 3 - Preferred Brand ✓ — — PA
Connect Gold RD CMS Standard Tier 3 - Preferred Brand ✓ — — PA
Connect Bronze 7000 HSA Indiv Med Deductible Tier 3 - Preferred Brand ✓ — — PA
Connect Silver 5000 Indiv Med Deductible Tier 3 - Preferred Brand ✓ — — PA
Connect myDiabetesCare Bronze Tier 3 - Preferred Brand ✓ — — PA
Connect Gold 1500 Indiv Med Deductible Tier 3 - Preferred Brand ✓ — — PA
Connect Bronze 6500 Indiv Med Deductible Tier 3 - Preferred Brand ✓ — — PA
Connect Bronze 5500 Indiv Med Deductible Tier 3 - Preferred Brand ✓ — — PA
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 12 hours, 31 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic ✓ — — PA
Troy Medicare (HMO) Tier 2 - Generic ✓ — — PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic ✓ — — PA
Alignment Health Platinum Select (HMO) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
Alignment Health Platinum (HMO) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
Alignment Health AVA (PPO) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
Alignment Health smartHMO (HMO) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
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