bismuth / metronidazole / tetracycline

Capsule

Also known as: Pylera

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

2 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 7 hours, 40 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Standard Option 2026 via Pylera	Tier 3 - Non-Preferred Brand	—	—	✓	QL
BCBS Federal Basic Option 2026 via Pylera	Tier 3 - Non-Preferred Brand	—	—	✓	QL

2 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 7 hours, 40 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC Medicaid Preferred Drug List 2026 via Pylera	Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026	Non-Preferred	—	—	—	None

3 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 7 hours, 40 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - HDHP 2026 via Pylera	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Pylera	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Pylera	Tier 3 - Non-Preferred Brand	—	—	—	None