bismuth subcitrate

140 MG — Capsule

Tetracycline-class Antimicrobial

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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  ·  Formulary date: Jan 1, 2026  ·  Checked: 7 hours, 34 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Everyday Bronze with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Silver + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Gold + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Expanded Bronze Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Silver Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Gold Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Expanded Bronze + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Elite Bronze with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Focused Silver with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Complete Gold with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Expanded Bronze with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Silver with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Gold with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Complete Gold + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Everyday Bronze + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Elite Bronze + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Focused Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Complete Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Complete Gold Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver $0 Rx Options Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Everyday Bronze Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Elite Bronze Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Enhanced CHF Heart Care Silver $0 Rx Options Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Streamlined Silver with Atrium Health Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Streamlined Silver Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 7 hours, 34 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Alignment Health AVA (PPO) Tier 4 - Non-Preferred — — — None
Alignment Health Platinum (HMO) Tier 4 - Non-Preferred — — — None
Alignment Health NC Duals (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Alignment Health smartHMO (HMO) Tier 4 - Non-Preferred — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 4 - Non-Preferred — — — None
Alignment Health Platinum Select (HMO) Tier 4 - Non-Preferred — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 4 - Non-Preferred — — — None
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