dichlorphenamide

50mg — Tablet

Also known as: dichlorphenamide tabs 50mg

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

8 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 17 hours, 24 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Focus 2026	Tier 2 - Preferred Brand	✓	—	—	PA
BCBS Federal Focus 2026 via ormalvi	Tier 2 - Preferred Brand	✓	—	—	PA
BCBS Federal Basic Option 2026	Tier 4 - Preferred Specialty	✓	—	—	PA
BCBS Federal Standard Option 2026	Tier 4 - Preferred Specialty	✓	—	—	PA
BCBS Federal Standard Option 2026 via ormalvi	Tier 4 - Preferred Specialty	✓	—	—	PA
BCBS Federal Basic Option 2026 via ormalvi	Tier 4 - Preferred Specialty	✓	—	—	PA
BCBS Federal Basic Option 2026 via Keveyis	Tier 5 - Non-Preferred Specialty	✓	—	—	PA
BCBS Federal Standard Option 2026 via Keveyis	Tier 5 - Non-Preferred Specialty	✓	—	—	PA

9 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 17 hours, 24 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - HDHP 2026 via ormalvi	Tier 4 - Specialty Generic	✓	—	✓	PA \| QL
NC State Health Plan - 80/20 Plus PPO 2026	Tier 4 - Specialty Generic	✓	—	✓	PA \| QL
NC State Health Plan - 70/30 Standard PPO 2026	Tier 4 - Specialty Generic	✓	—	✓	PA \| QL
NC State Health Plan - HDHP 2026	Tier 4 - Specialty Generic	✓	—	✓	PA \| QL
NC State Health Plan - 80/20 Plus PPO 2026 via ormalvi	Tier 4 - Specialty Generic	✓	—	✓	PA \| QL
NC State Health Plan - 70/30 Standard PPO 2026 via ormalvi	Tier 4 - Specialty Generic	✓	—	✓	PA \| QL
NC State Health Plan - 80/20 Plus PPO 2026 via Keveyis	Tier 6 - Non-Preferred Brand Specialty	✓	—	✓	PA \| QL
NC State Health Plan - 70/30 Standard PPO 2026 via Keveyis	Tier 6 - Non-Preferred Brand Specialty	✓	—	✓	PA \| QL
NC State Health Plan - HDHP 2026 via Keveyis	Tier 6 - Non-Preferred Brand Specialty	✓	—	✓	PA \| QL