dipyridamole
25 mg, 50 mg, 75 mg — Tablet
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
Dipyridamole Oral Tablet
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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 with Atrium Health | 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 |
| Elite Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Focused Silver with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze 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 |
| Complete Gold | Tier 2 - Generic | — | — | — | None |
AmeriHealth Caritas NC
10 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Gold Signature + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Essential + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Gold Premier + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Premier + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Signature + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Essential + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Signature + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 2 - Generic | — | — | — | None |
Blue Cross Blue Shield Federal
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBS Federal Focus 2026 | Tier 1 - Generic | — | — | — | None |
| BCBS Federal Basic Option 2026 | Tier 1 - Generic | — | — | — | None |
| BCBS Federal Standard Option 2026 | Tier 1 - Generic | — | — | — | None |
Blue Cross Blue Shield of NC
5 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBSNC Blue Home with UNC Health Alliance 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 Care 2026 | Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
| BCBSNC Blue Local 2026 | Tier 2 - Medium Cost Generic/Brand | — | — | — | None |
Cigna
20 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Connect Silver 3500 Indiv Med Deductible | 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 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 Gold RD CMS Standard | Tier 2 - Generic | — | — | — | None |
| Connect Bronze CMS Standard | Tier 2 - Generic | — | — | — | None |
Medicare Part D
76 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| PruittHealth Premier (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Liberty Medicare Dual Plan (HMO D-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Alignment Health AVA (PPO) | Tier 2 - Generic | — | — | — | None |
| Troy Medicare (HMO) | Tier 2 - Generic | ✓ | — | — | PA |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 2 - Generic | ✓ | — | — | PA |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 2 - Generic | ✓ | — | — | PA |
| Alignment Health Platinum (HMO) | 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 smartHMO (HMO) | Tier 2 - Generic | — | — | — | None |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Alignment Health Platinum Select (HMO) | Tier 2 - Generic | — | — | — | 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 GIVEBACK 002 NC (HMO) | Tier 3 - Preferred Brand | ✓ | — | — | PA |
| DEVOTED CORE 001 NC (HMO) | Tier 3 - Preferred Brand | ✓ | — | — | PA |
| HealthSpring True Choice (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 3 - Preferred Brand | ✓ | — | — | PA |
| 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 |
| HealthSpring Preferred (HMO) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| 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 008 NC (PPO) | Tier 3 - Preferred Brand | ✓ | — | — | PA |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | Tier 3 - Preferred Brand | ✓ | — | — | PA |
| HealthSpring TotalCare (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| 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 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 |
| Wellcare Dual Liberty Open (PPO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Assist Open (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Dual Access (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Dual Liberty (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Wellcare Dual Reserve (HMO-POS D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Enhanced (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Enhanced (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Enhanced (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Signature Extra (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 Giveback (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Signature (PPO) | 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 Chronic Care (HMO C-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Prime (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
NC Medicaid PDL
1 planNC State Health Plan
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| 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 |
| NC State Health Plan - 70/30 Standard PPO 2026 | Tier 1 - Preferred Generic | — | — | — | None |
Oscar Health
28 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Silver Simple PCP Saver | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Gold Elite Saver Plus | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Simple Chronic Care CKM | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Simple Diabetes | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Classic 4700 | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Simple Women's Health with Menopause Benefits | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| AIAN Cost Share | Tier 2 - Generic | — | — | — | None |
| AIAN Cost Share | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Simple Chronic Care CKM | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Elite + PCP Saver Plus | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Classic | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Simple Diabetes | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Classic Standard | Tier 2 - Generic | — | — | — | None |
| Gold Classic Standard | Tier 2 - Generic | — | — | — | None |
| Bronze Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Silver Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Gold Classic Standard | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Elite + PCP Saver Plus | Tier 2 - Generic | — | — | — | None |
| Silver Classic | Tier 2 - Generic | — | — | — | None |
| Secure | Tier 2 - Generic | — | — | — | None |
| Bronze Classic 4700 | Tier 2 - Generic | — | — | — | None |
| Silver Simple PCP Saver | Tier 2 - Generic | — | — | — | None |
| Gold Elite Saver Plus | Tier 2 - Generic | — | — | — | None |
| Silver Simple Diabetes | Tier 2 - Generic | — | — | — | None |
| Secure | with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Bronze Classic Standard | Tier 2 - Generic | — | — | — | None |
UnitedHealthcare
13 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Standard+ Dental + Vision (No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Standard (No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Standard (No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Value ($0 Virtual Urgent Care, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold Standard (No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |