doxylamine-pyridoxine

10 mg — Tablet

Also known as: Diclegis doxylamine-pyridoxine tab delayed release 10- 10 mg doxylamine-pyridoxine tab delayed release 10-

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

5 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 14 hours, 2 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Basic Option 2026	Tier 1 - Generic	✓	—	—	PA
BCBS Federal Standard Option 2026	Tier 1 - Generic	✓	—	—	PA
BCBS Federal Focus 2026	Tier 1 - Generic	✓	—	—	PA
BCBS Federal Basic Option 2026 via Diclegis	Tier 3 - Non-Preferred Brand	✓	—	—	PA
BCBS Federal Standard Option 2026 via Diclegis	Tier 3 - Non-Preferred Brand	✓	—	—	PA

2 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 14 hours, 2 minutes ago

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

6 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 14 hours, 2 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 - HDHP 2026	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Diclegis	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Diclegis	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - HDHP 2026 via Diclegis	Tier 3 - Non-Preferred Brand	—	—	—	None

1 plan

Source: PDF · Formulary date: Jan 1, 2026 · Checked: 14 hours, 2 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
UnitedHealthcare NC Individual & Family 2026	Tier 4 - Higher Cost	—	—	—	None