Dipentum

Generic: olsalazine sodium

250 MG — Capsule

Aminosalicylates

Also known as: DIPENTUM CAPS 250MG olsalazine sodium Dipentum 250 Mg 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: Jan 1, 2026  ·  Checked: 1 hour, 27 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Standard Silver with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Standard Gold with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Standard Silver with Atrium Health Tier 3 - Preferred Brand — — — None
Standard Gold with Atrium Health Tier 3 - Preferred Brand — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Complete Gold + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Everyday Bronze + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Elite Bronze + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Focused Silver with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Complete Gold with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Standard Silver + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Standard Gold + Vision + Adult Dental Tier 3 - Preferred Brand — — — None
Complete Gold Tier 3 - Preferred Brand — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 3 - Preferred Brand — — — None
Everyday Bronze Tier 3 - Preferred Brand — — — None
Elite Bronze Tier 3 - Preferred Brand — — — None
Clear Silver with $0 Insulin Options Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze Tier 3 - Preferred Brand — — — None
Standard Silver Tier 3 - Preferred Brand — — — None
Standard Gold Tier 3 - Preferred Brand — — — None
Everyday Bronze with Atrium Health Tier 3 - Preferred Brand — — — None
Elite Bronze with Atrium Health Tier 3 - Preferred Brand — — — None
Focused Silver with Atrium Health Tier 3 - Preferred Brand — — — None
Complete Gold with Atrium Health Tier 3 - Preferred Brand — — — None
Standard Expanded Bronze with Atrium Health Tier 3 - Preferred Brand — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 1 hour, 27 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Standard Option 2026 Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Basic Option 2026 Tier 3 - Non-Preferred Brand — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 1 hour, 27 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Cigna Plus NC 4-Tier Formulary 2026 Tier 3 - Non-Preferred — — — None
Source: CMS QHP JSON  ·  Formulary date: Mar 18, 2026  ·  Checked: 1 hour, 27 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Alignment Health Platinum Select (HMO) Tier 5 - Specialty — — — None
Alignment Health Platinum (HMO) Tier 5 - Specialty — — — None
Alignment Health NC Duals (HMO-POS D-SNP) Tier 5 - Specialty — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 5 - Specialty — — — None
Alignment Health smartHMO (HMO) Tier 5 - Specialty — — — None
Alignment Health AVA (PPO) Tier 5 - Specialty — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 5 - Specialty — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 1 hour, 27 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026 Non-Preferred — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 1 hour, 27 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026 Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 70/30 Standard PPO 2026 Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 80/20 Plus PPO 2026 Tier 3 - Non-Preferred Brand — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 1 hour, 27 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UnitedHealthcare NC Individual & Family 2026 Tier 4 - Higher Cost — — — None
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