ELETRIPTAN HBR

20 MG, 40 MG — Tablet

Serotonin-1b and Serotonin-1d Receptor Agonist

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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: PDF  ·  Formulary date: Oct 15, 2026  ·  Checked: 18 hours, 26 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Bronze 5500 Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 3000 Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Connect Silver CMS Standard Tier 3 - Preferred Brand — — ✓ QL
Connect myDiabetesCare Silver Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 3600 Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze CMS Standard Tier 3 - Preferred Brand — — ✓ QL
Connect Gold CMS Standard Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD 6000 Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD CMS Standard Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 3500 Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 5000 Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD CMS Standard Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 2200 Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Connect Gold RD CMS Standard Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 7000 HSA Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 5000 Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Connect myDiabetesCare Bronze Tier 3 - Preferred Brand — — ✓ QL
Connect Gold 1500 Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD 5000 Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 6500 Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 18 hours, 26 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 2 - Generic — — ✓ 12 per 30 days QL
Aetna Medicare Signature (HMO) Tier 2 - Generic — — ✓ 12 per 30 days QL
Aetna Medicare Dual (HMO D-SNP) Tier 2 - Generic — — ✓ 12 per 30 days QL
Aetna Medicare Signature (HMO) Tier 2 - Generic — — ✓ 12 per 30 days QL
Aetna Medicare Value Plus (HMO) Tier 2 - Generic — — ✓ 12 per 30 days QL
Aetna Medicare Prime (HMO) Tier 2 - Generic — — ✓ 12 per 30 days QL
Aetna Medicare Signature Care (HMO) Tier 2 - Generic — — ✓ 12 per 30 days QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 2 - Generic — — ✓ 12 per 30 days QL
Aetna Medicare Enhanced (HMO) Tier 2 - Generic — — ✓ 12 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 2 - Generic — — ✓ 12 per 30 days QL
Aetna Medicare Signature (PPO) Tier 2 - Generic — — ✓ 12 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 2 - Generic — — ✓ 12 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 2 - Generic — — ✓ 12 per 30 days QL
Aetna Medicare Signature Extra (PPO) Tier 2 - Generic — — ✓ 12 per 30 days QL
Aetna Medicare Signature (PPO) Tier 2 - Generic — — ✓ 12 per 30 days QL
Aetna Medicare Signature (PPO) Tier 2 - Generic — — ✓ 12 per 30 days QL
Aetna Medicare Signature Giveback (PPO) Tier 2 - Generic — — ✓ 12 per 30 days QL
Aetna Medicare Signature (PPO) Tier 2 - Generic — — ✓ 12 per 30 days QL
Alignment Health smartHMO (HMO) Tier 3 - Preferred Brand — — ✓ 12 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 3 - Preferred Brand — — ✓ 12 per 30 days QL
Alignment Health Platinum Select (HMO) Tier 3 - Preferred Brand — — ✓ 12 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 12 per 30 days QL
Alignment Health AVA (PPO) Tier 3 - Preferred Brand — — ✓ 12 per 30 days QL
Alignment Health Platinum (HMO) Tier 3 - Preferred Brand — — ✓ 12 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 12 per 30 days QL
Humana Gold Choice H8145-004 (PFFS) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
Humana Gold Plus H1036-335 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
Humana Full Access H5525-034 (PPO) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
HumanaChoice Giveback H5525-035 (PPO) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
HumanaChoice H5525-049 (PPO) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
HumanaChoice H5525-050 (PPO) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
HumanaChoice H5525-070 (PPO) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
Humana Dual Select H5525-072 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
HumanaChoice H5525-083 (PPO) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
Humana Gold Plus H6622-025 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
Humana Gold Plus H6622-026 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
Humana Gold Plus H1036-137 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
Humana Gold Plus H6622-057 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
Humana Gold Plus H6622-060 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
HumanaChoice Giveback H5216-017 (PPO) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
HumanaChoice H5216-211 (PPO) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
Humana Gold Plus H1036-233 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
Humana Dual Select H1036-307 (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
Humana Gold Plus H6622-061 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 9 per 30 days QL
Source: Excel (XLSX)  ·  Formulary date: Sep 23, 2026  ·  Checked: 18 hours, 26 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026 Tier 1 - Generic Formulary ✓ — ✓ RELPAX TO BE DISPENSED AT MAX QUANTITY OF 12 TABS IN 22 DAYS OR 36 TABS IN 68 DAYS PA | QL PA: TPA - UBRELVY W/O USE OF NURTEC ODT TABLET OR W/O USE OF SELECT TRIPTANS IN LAST 180 DAYS REQ PA; Quantity limit
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