bromfenac

Ophthalmic Solution

Anti-Inflammatory

Also known as: Prolensa, Xibrom, BromSite
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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: 2 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 2 - Generic — — — None
Standard Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Elite Bronze with Atrium Health Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health Tier 2 - Generic — — — None
Standard Gold Tier 2 - Generic — — — None
Standard Silver Tier 2 - Generic — — — None
Standard Expanded Bronze Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options Tier 2 - Generic — — — None
Elite Bronze Tier 2 - Generic — — — None
Everyday Bronze Tier 2 - Generic — — — None
Complete Gold Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Gold + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Silver + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Expanded Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Elite Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Everyday Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Complete Gold + Vision + Adult Dental Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Gold with Atrium Health Tier 2 - Generic — — — None
Standard Silver with Atrium Health Tier 2 - Generic — — — None
Standard Expanded Bronze with Atrium Health Tier 2 - Generic — — — None
Complete Gold with Atrium Health Tier 2 - Generic — — — None
Focused Silver with Atrium Health Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 2 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Standard Option 2026
via Prolensa 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Basic Option 2026
via BromSite 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Standard Option 2026
via BromSite 		Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Basic Option 2026
via Prolensa 		Tier 3 - Non-Preferred Brand — — — None
Source: CMS QHP JSON  ·  Formulary date: Mar 18, 2026  ·  Checked: 2 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 12 per 365 days QL
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 12 per 365 days QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 12 per 365 days QL
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic — — — None
Alignment Health Platinum Select (HMO)
via Prolensa 		Tier 3 - Preferred Brand — — — None
Wellcare Simple Open (PPO)
via Prolensa 		Tier 3 - Preferred Brand — — — None
Wellcare Simple (HMO-POS)
via Prolensa 		Tier 3 - Preferred Brand — — — None
Wellcare Giveback Open (PPO)
via Prolensa 		Tier 3 - Preferred Brand — — — None
Alignment Health Platinum (HMO)
via Prolensa 		Tier 3 - Preferred Brand — — — None
Alignment Health NC Duals (HMO-POS D-SNP)
via Prolensa 		Tier 3 - Preferred Brand — — — None
Alignment Health smartHMO (HMO)
via Prolensa 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Prolensa 		Tier 3 - Preferred Brand — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Prolensa 		Tier 3 - Preferred Brand — — — None
Alignment Health AVA (PPO)
via Prolensa 		Tier 3 - Preferred Brand — — — None
Wellcare Dual Liberty Open (PPO D-SNP)
via Prolensa 		Tier 3 - Preferred Brand — — — None
Wellcare Assist Open (PPO)
via Prolensa 		Tier 3 - Preferred Brand — — — None
Wellcare Dual Access (HMO-POS D-SNP)
via Prolensa 		Tier 3 - Preferred Brand — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via Prolensa 		Tier 3 - Preferred Brand — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via Prolensa 		Tier 3 - Preferred Brand — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred — — — None
Wellcare Giveback Open (PPO) Tier 4 - Non-Preferred — — — None
Blue Medicare PPO Enhanced (PPO) Tier 4 - Non-Preferred — — — None
Blue Medicare Essential Plus (HMO-POS) Tier 4 - Non-Preferred — — — None
Blue Medicare Enhanced (HMO-POS) Tier 4 - Non-Preferred — — — None
Blue Medicare Choice (HMO) Tier 4 - Non-Preferred — — — None
Blue Medicare Essential (HMO) Tier 4 - Non-Preferred — — — None
Experience Health Medicare Advantage (HMO) Tier 4 - Non-Preferred — — — None
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Value Plus (HMO) 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
Alignment Health AVA (PPO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan I (PPO) Tier 4 - Non-Preferred — — ✓ 12 per 365 days QL
HealthTeam Advantage Plan II (PPO) Tier 4 - Non-Preferred — — ✓ 12 per 365 days QL
HealthTeam Advantage Vitality Plan (PPO) Tier 4 - Non-Preferred — — ✓ 12 per 365 days QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 12 per 365 days QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty Open (PPO D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Assist Open (PPO) Tier 4 - Non-Preferred — — — None
Wellcare Dual Access (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Plus (HMO) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Savings (HMO) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Select (HMO) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred (HMO) Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare Plus (HMO D-SNP) Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare (HMO D-SNP) Tier 4 - Non-Preferred — — — None
HealthSpring True Choice (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Giveback (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Extra (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — — None
Wellcare Simple Open (PPO) Tier 4 - Non-Preferred — — — None
Wellcare Simple (HMO-POS) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 2 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026
via BromSite 		Non-Preferred — — — None
NC Medicaid Preferred Drug List 2026 Non-Preferred — — — None
NC Medicaid Preferred Drug List 2026
via Prolensa 		Non-Preferred — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 2 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 80/20 Plus PPO 2026
via Prolensa 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - HDHP 2026
via Prolensa 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Prolensa 		Tier 2 - Non-Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via BromSite 		Not Covered — — — None
NC State Health Plan - HDHP 2026
via BromSite 		Not Covered — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via BromSite 		Not Covered — — — None
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