chlorpheniramine polistirex
1.6 MG — Suspension
Histamine-1 Receptor Antagonist
Also known as:
HYDROCODONE-CHLORPHEN ER SUSP
Hydrocod Poli-Chlorphe Poli ER Oral Suspension Extended Release
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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.
Ambetter (Centene)
29 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Complete Gold | Tier 2 - Generic | — | — | — | None |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze | Tier 2 - Generic | — | — | — | None |
| Elite Bronze | Tier 2 - Generic | — | — | — | None |
| Clear Silver with $0 Insulin Options | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze | Tier 2 - Generic | — | — | — | None |
| Standard Silver | Tier 2 - Generic | — | — | — | None |
| Standard Gold | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Elite Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Focused Silver with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Complete Gold with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Standard Silver with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Standard Gold with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Complete Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Elite Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Focused Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Complete Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Silver + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
AmeriHealth Caritas NC
10 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Silver Essential + No Referrals | Tier 2 - Generic | — | — | ✓ | QL |
| AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals | Tier 2 - Generic | — | — | ✓ | QL |
| AmeriHealth Caritas Next Silver Signature + No Referrals | Tier 2 - Generic | — | — | ✓ | QL |
| AmeriHealth Caritas Next Bronze Signature + No Referrals | Tier 2 - Generic | — | — | ✓ | QL |
| AmeriHealth Caritas Next Gold Signature + No Referrals | Tier 2 - Generic | — | — | ✓ | QL |
| AmeriHealth Caritas Next Bronze Essential + No Referrals | Tier 2 - Generic | — | — | ✓ | QL |
| AmeriHealth Caritas Next Gold Premier + No Referrals | Tier 2 - Generic | — | — | ✓ | QL |
| AmeriHealth Caritas Next Bronze Premier + No Referrals | Tier 2 - Generic | — | — | ✓ | QL |
| AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals | Tier 2 - Generic | — | — | ✓ | QL |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 2 - Generic | — | — | ✓ | QL |
Cigna
20 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Connect Gold RD CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect myDiabetesCare Silver | Tier 2 - Generic | — | — | — | None |
| Connect Silver RD 2200 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Gold 1500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect myDiabetesCare Bronze | Tier 2 - Generic | — | — | — | None |
| Connect Bronze 5500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze RD 6000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver 3500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze RD 5000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver RD 3500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze 7000 HSA Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver 4400 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver RD 5000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver 3000 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Bronze 6500 Indiv Med Deductible | Tier 2 - Generic | — | — | — | None |
| Connect Silver CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Silver RD CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Gold CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Bronze RD CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Bronze CMS Standard | Tier 2 - Generic | — | — | — | None |
Oscar Health
28 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Silver Simple Women's Health with Menopause Benefits | with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Gold Elite Saver Plus | with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Bronze Simple Chronic Care CKM | with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Silver Simple Chronic Care CKM | with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Bronze Classic Standard | Tier 2 - Generic | — | — | ✓ | QL |
| Silver Classic Standard | Tier 2 - Generic | — | — | ✓ | QL |
| Gold Classic Standard | Tier 2 - Generic | — | — | ✓ | QL |
| Bronze Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Silver Simple Diabetes | Tier 2 - Generic | — | — | ✓ | QL |
| Bronze Simple Diabetes | with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| AIAN Cost Share | Tier 2 - Generic | — | — | ✓ | QL |
| AIAN Cost Share | with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Bronze Classic 4700 | with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Secure | with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Gold Elite Saver Plus | Tier 2 - Generic | — | — | ✓ | QL |
| Silver Simple PCP Saver | Tier 2 - Generic | — | — | ✓ | QL |
| Bronze Classic 4700 | Tier 2 - Generic | — | — | ✓ | QL |
| Secure | Tier 2 - Generic | — | — | ✓ | QL |
| Silver Classic | Tier 2 - Generic | — | — | ✓ | QL |
| Bronze Elite + PCP Saver Plus | Tier 2 - Generic | — | — | ✓ | QL |
| Gold Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Bronze Elite + PCP Saver Plus | with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Silver Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Silver Classic | with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Silver Simple Diabetes | with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
| Silver Simple PCP Saver | with Atrium Health | Tier 2 - Generic | — | — | ✓ | QL |
UnitedHealthcare
13 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Silver Standard (No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Bronze Standard+ Dental + Vision (No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Silver Value ($0 Virtual Urgent Care, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Gold Standard (No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Bronze Standard (No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |