DOXYLAMINE

25MG

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

1 plan

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 12 hours, 26 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Standard Option 2026 via Bonjesta	Tier 3 - Non-Preferred Brand	✓	—	—	PA

1 plan

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 12 hours, 26 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC Medicaid Preferred Drug List 2026 via Bonjesta	Non-Preferred	—	—	—	None

3 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 12 hours, 26 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - 80/20 Plus PPO 2026 via Bonjesta	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Bonjesta	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - HDHP 2026 via Bonjesta	Tier 3 - Non-Preferred Brand	—	—	—	None

1 plan

Source: Excel (XLSX) · Formulary date: Jan 5, 2026 · Checked: 12 hours, 26 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 1 - Basic Core Formulary	—	—	—	None