dabigatran etexilate mesylate

110 mg, 150 mg, 20 mg, 30 mg, 40 mg, 50 mg — Capsule

ANTICOAGULANTS

Also known as: dabigatran etexilate mesylate caps 75mg, 110mg, 150mg dabigatran etexilate mesylate cap 75 mg (etexilate base eq), 110 mg (etexilate base eq), 150 mg (etexilate base eq) PRADAXA dabigatran etexilate mesylate cap 75 mg (etexilate base eq), 110 mg (etexilate base eq), dabigatran etexilate mesylate caps 75mg, Dabigatran Etexilate Mesylate 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.
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 21 hours, 4 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — ✓ QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 21 hours, 4 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Basic Option 2026 Tier 1 - Generic — — — None
BCBS Federal Focus 2026 Tier 1 - Generic — — — None
BCBS Federal Standard Option 2026 Tier 1 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 21 hours, 4 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Liberty Medicare Advantage (HMO C-SNP) Tier 2 - Generic — — ✓ 60 per 30 days QL
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 2 - Generic — — ✓ 60 per 30 days QL
Senior Care (HMO I-SNP) Tier 2 - Generic — — ✓ 60 per 30 days QL
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic — — ✓ 60 per 30 days QL
Troy Medicare (HMO) Tier 2 - Generic — — ✓ 60 per 30 days QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic — — ✓ 60 per 30 days QL
Wellcare Dual Liberty Open (PPO D-SNP) Tier 2 - Generic — — ✓ 60 per 30 days QL
Wellcare Assist Open (PPO) Tier 2 - Generic — — ✓ 60 per 30 days QL
Wellcare Giveback Open (PPO) Tier 2 - Generic — — ✓ 60 per 30 days QL
Wellcare Simple Open (PPO) Tier 2 - Generic — — ✓ 60 per 30 days QL
Wellcare Simple (HMO-POS) Tier 2 - Generic — — ✓ 60 per 30 days QL
Wellcare Dual Access (HMO-POS D-SNP) Tier 2 - Generic — — ✓ 60 per 30 days QL
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 2 - Generic — — ✓ 60 per 30 days QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED GIVEBACK 012 NC (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED GIVEBACK 002 NC (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CORE 001 NC (HMO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CHOICE 008 NC (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CHOICE 005 NC (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CHOICE 003 NC (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED CHOICE 001 NC (PPO) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 60 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Aetna Medicare Signature Giveback (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Humana Full Access H5525-034 (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
HumanaChoice Giveback H5525-035 (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
HumanaChoice H5525-049 (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
HumanaChoice H5525-050 (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
HumanaChoice H5525-070 (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Humana Dual Select H5525-072 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
HumanaChoice H5525-083 (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Erickson Advantage Signature (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Erickson Advantage Champion (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Erickson Advantage Freedom (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Erickson Advantage Liberty (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Humana Gold Plus H6622-025 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Humana Gold Plus H6622-026 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Humana Gold Plus H6622-057 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Humana Gold Plus H6622-060 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Humana Gold Plus H6622-061 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Alignment Health AVA (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
HealthSpring True Choice (PPO) Tier 4 - Non-Preferred — — — None
Humana Gold Choice H8145-004 (PFFS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Alignment Health Platinum (HMO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
HealthSpring Preferred (HMO) Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare Plus (HMO D-SNP) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Select (HMO) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Savings (HMO) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Plus (HMO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan I (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
HealthSpring TotalCare (HMO D-SNP) Tier 4 - Non-Preferred — — — None
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
HealthTeam Advantage Vitality Plan (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Experience Health Medicare Advantage (HMO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
HealthTeam Advantage Plan II (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Humana Gold Plus H1036-335 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Humana Gold Plus H1036-137 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Blue Medicare PPO Enhanced (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Blue Medicare Essential Plus (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Blue Medicare Enhanced (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Blue Medicare Choice (HMO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Blue Medicare Essential (HMO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
HumanaChoice Giveback H5216-017 (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
HumanaChoice H5216-211 (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Humana Gold Plus H1036-233 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Humana Dual Select H1036-307 (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Alignment Health smartHMO (HMO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Alignment Health Platinum Select (HMO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Aetna Medicare Signature Extra (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred — — ✓ 60 per 30 days QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 21 hours, 4 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 70/30 Standard PPO 2026 Tier 1 - Preferred Generic — — — None
NC State Health Plan - HDHP 2026 Tier 1 - Preferred Generic — — — None
NC State Health Plan - 80/20 Plus PPO 2026 Tier 1 - Preferred Generic — — — None
Source: Excel (XLSX)  ·  Formulary date: Jul 31, 2026  ·  Checked: 21 hours, 4 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026 Tier 3 - Non-Formulary ✓ — — PA
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