BUTALBITAL-ASPIRIN-CAFFEINE CP
40 MG — Capsule
Platelet Aggregation Inhibitor
Also known as:
Butalbital-ASA-Caffeine Oral 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.
AmeriHealth Caritas NC
7 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Bronze Signature + No Referrals | Tier 2 - Generic | — | — | ✓ | QL |
| AmeriHealth Caritas Next Bronze Essential + No Referrals | Tier 2 - Generic | — | — | ✓ | QL |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 2 - Generic | — | — | ✓ | QL |
| AmeriHealth Caritas Next Bronze Premier + No Referrals | Tier 2 - Generic | — | — | ✓ | QL |
| AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals | Tier 2 - Generic | — | — | ✓ | QL |
| AmeriHealth Caritas Next Gold Signature + No Referrals | Tier 2 - Generic | — | — | ✓ | QL |
| AmeriHealth Caritas Next Silver Signature + No Referrals | Tier 2 - Generic | — | — | ✓ | QL |
Cigna
20 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Connect Silver RD CMS Standard | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Bronze 6500 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Silver RD 3500 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Gold 1500 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Bronze 5500 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Silver RD 5000 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Bronze RD 5000 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Silver 4400 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Silver RD 2200 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Bronze RD 6000 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect myDiabetesCare Silver | Tier 2 - Generic | — | — | ✓ | QL |
| Connect myDiabetesCare Bronze | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Silver 3500 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Bronze 7000 HSA Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Silver 3000 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Silver CMS Standard | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Gold RD CMS Standard | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Gold CMS Standard | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Bronze CMS Standard | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Bronze RD CMS Standard | Tier 2 - Generic | — | — | ✓ | QL |
Medicare Part D
49 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Troy Medicare (HMO) | Tier 2 - Generic | ✓ | — | — | PA |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 2 - Generic | ✓ | — | — | PA |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 2 - Generic | ✓ | — | — | PA |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Erickson Advantage Signature (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| UHC Dual Complete NC-S3 (HMO-POS D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0015 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| UHC Dual Complete NC-V001 (HMO-POS D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0012 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0011 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| UHC Complete Care NC-27 (HMO-POS C-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| UHC Complete Care NC-28 (HMO-POS C-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Erickson Advantage Champion (HMO-POS C-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0009 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0008 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| UHC Dual Complete NC-D001 (HMO-POS D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0007 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0022 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0021 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0019 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Blue Medicare PPO Enhanced (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Blue Medicare Essential Plus (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Blue Medicare Enhanced (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Blue Medicare Choice (HMO) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Blue Medicare Essential (HMO) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Experience Health Medicare Advantage (HMO) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Healthy Blue + Medicare (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 NC Duals (HMO-POS D-SNP) | 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 |
| 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 AVA (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| UHC Dual Complete NC-S2 (PPO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| UHC Dual Complete NC-S001 (PPO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0017 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0016 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0004 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| AARP Medicare Advantage from UHC NC-0001 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| AARP Medicare Advantage Access from UHC NC-23 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Erickson Advantage Liberty (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Erickson Advantage Freedom (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |