dipyridamole

25 mg, 50 mg, 75 mg — Tablet

HEMATOLOGICAL AGENTS - MISC.

Also known as: dipyridamole oral Persantine dipyridamole tabs 25mg, 50mg, 75mg dipyridamole tab 25 mg, 50 mg, 75 mg Dipyridamole 25 Mg Tablet Dipyridamole 50 Mg Tablet Dipyridamole 75 Mg Tablet
GoodRx Compare Prices

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, 46 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
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
Standard Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Silver with Atrium Health + Vision + Adult Dental 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
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Gold + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Silver + Vision + Adult Dental Tier 2 - Generic — — — None
Standard Expanded Bronze + Vision + Adult Dental Tier 2 - Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — — None
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
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 1 hour, 46 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Focus 2026 Tier 1 - Generic — — — None
BCBS Federal Standard Option 2026 Tier 1 - Generic — — — None
BCBS Federal Basic Option 2026 Tier 1 - Generic — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 1 hour, 46 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Local 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Care 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Value 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Advantage 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 2 - Medium Cost Generic/Brand — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 1 hour, 46 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Cigna Plus NC 4-Tier Formulary 2026 Tier 1 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Mar 18, 2026  ·  Checked: 1 hour, 46 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Alignment Health AVA (PPO) Tier 2 - Generic — — — None
Alignment Health NC Duals (HMO-POS D-SNP) Tier 2 - Generic — — — None
Senior Care (HMO I-SNP) Tier 2 - Generic — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic ✓ — — PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic ✓ — — PA
Troy Medicare (HMO) Tier 2 - Generic ✓ — — PA
Alignment Health Platinum Select (HMO) Tier 2 - Generic — — — None
Alignment Health Platinum (HMO) Tier 2 - Generic — — — None
Liberty Medicare Advantage (HMO C-SNP) Tier 2 - Generic — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 2 - Generic — — — None
Alignment Health smartHMO (HMO) Tier 2 - Generic — — — None
DEVOTED CHOICE 008 NC (PPO) Tier 3 - Preferred Brand ✓ — — PA
HealthSpring True Choice (PPO) Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare (HMO D-SNP) Tier 3 - Preferred Brand — — — None
HealthSpring TotalCare Plus (HMO D-SNP) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Select (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Savings (HMO) Tier 3 - Preferred Brand — — — None
HealthSpring Preferred Plus (HMO) Tier 3 - Preferred Brand — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED CORE 001 NC (HMO) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED GIVEBACK 002 NC (HMO) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED GIVEBACK 012 NC (HMO) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED CHOICE 001 NC (PPO) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED CHOICE 003 NC (PPO) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED CHOICE 005 NC (PPO) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 3 - Preferred Brand ✓ — — PA
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 3 - Preferred Brand ✓ — — PA
Wellcare Assist Open (PPO) Tier 4 - Non-Preferred — — — None
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Wellcare Dual Access (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature Giveback (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature Extra (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Simple Open (PPO) Tier 4 - Non-Preferred — — — None
Wellcare Simple (HMO-POS) Tier 4 - Non-Preferred — — — None
Wellcare Giveback Open (PPO) Tier 4 - Non-Preferred — — — None
Blue Medicare PPO Enhanced (PPO) Tier 4 - Non-Preferred — — — None
Blue Medicare Essential Plus (HMO-POS) Tier 4 - Non-Preferred — — — None
Blue Medicare Enhanced (HMO-POS) Tier 4 - Non-Preferred — — — None
Blue Medicare Choice (HMO) Tier 4 - Non-Preferred — — — None
Blue Medicare Essential (HMO) Tier 4 - Non-Preferred — — — None
Experience Health Medicare Advantage (HMO) Tier 4 - Non-Preferred — — — None
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred ✓ — — PA
Wellcare Dual Liberty Open (PPO D-SNP) Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 1 hour, 46 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026 Preferred — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 1 hour, 46 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 80/20 Plus PPO 2026 Tier 1 - Preferred Generic — — — None
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
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 1 hour, 46 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UnitedHealthcare NC Individual & Family 2026 Tier 2 - Lower Cost — — — None
Something not right?