Elmiron

Generic: pentosan polysulfate

100 MG — Capsule

VAGINAL PRODUCTS

Also known as: ELMIRON CAPS 100MG pentosan polysulfate Elmiron 100 Mg Capsule
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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: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 12 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Standard Silver + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Focused Silver with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Complete Gold + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Standard Expanded Bronze + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Complete Gold with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Standard Gold + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Standard Silver with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Standard Gold with Atrium Health + Vision + Adult Dental Tier 3 - Preferred Brand — — ✓ QL
Standard Gold with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Standard Silver with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Standard Expanded Bronze with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Complete Gold Tier 3 - Preferred Brand — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 3 - Preferred Brand — — ✓ QL
Everyday Bronze Tier 3 - Preferred Brand — — ✓ QL
Elite Bronze Tier 3 - Preferred Brand — — ✓ QL
Clear Silver with $0 Insulin Options Tier 3 - Preferred Brand — — ✓ QL
Standard Expanded Bronze Tier 3 - Preferred Brand — — ✓ QL
Standard Silver Tier 3 - Preferred Brand — — ✓ QL
Standard Gold Tier 3 - Preferred Brand — — ✓ QL
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 12 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Focus 2026 Tier 2 - Preferred Brand — — — None
BCBS Federal Standard Option 2026 Tier 2 - Preferred Brand — — — None
BCBS Federal Basic Option 2026 Tier 2 - Preferred Brand — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 12 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Advantage 2026 Tier 4 - Higher Cost Brand ✓ — — Restricted Access PA
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 4 - Higher Cost Brand ✓ — — Restricted Access PA
BCBSNC Blue Local 2026 Tier 4 - Higher Cost Brand ✓ — — Restricted Access PA
BCBSNC Blue Care 2026 Tier 4 - Higher Cost Brand ✓ — — Restricted Access PA
BCBSNC Blue Value 2026 Tier 4 - Higher Cost Brand ✓ — — Restricted Access PA
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 12 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Cigna Plus NC 4-Tier Formulary 2026 Tier 3 - Non-Preferred — — — None
Source: CMS QHP JSON  ·  Formulary date: Mar 18, 2026  ·  Checked: 12 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Wellcare Dual Access (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
Wellcare Dual Liberty Open (PPO D-SNP) Tier 3 - Preferred Brand — — — None
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 3 - Preferred Brand — — — None
Wellcare Assist Open (PPO) Tier 3 - Preferred Brand — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
HealthSpring True Choice (PPO) Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare (HMO D-SNP) Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare Plus (HMO D-SNP) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred (HMO) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Select (HMO) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Savings (HMO) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Plus (HMO) Tier 4 - Non-Preferred — — — None
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
HealthTeam Advantage Plan I (PPO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Plan II (PPO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Vitality Plan (PPO) Tier 4 - Non-Preferred — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Troy Medicare (HMO) Tier 4 - Non-Preferred — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 4 - Non-Preferred — — — None
HumanaChoice H5525-050 (PPO) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
HumanaChoice H5525-070 (PPO) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Humana Dual Select H5525-072 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
HumanaChoice H5525-083 (PPO) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Humana Gold Plus H6622-025 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Humana Gold Plus H6622-026 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Humana Gold Plus H6622-057 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Humana Gold Plus H6622-060 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Humana Gold Plus H6622-061 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Humana Gold Choice H8145-004 (PFFS) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Humana Gold Plus H1036-137 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Humana Gold Plus H1036-233 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Humana Dual Select H1036-307 (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Humana Gold Plus H1036-335 (HMO-POS) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
HumanaChoice Giveback H5216-017 (PPO) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
HumanaChoice H5216-211 (PPO) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Humana Full Access H5525-034 (PPO) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
HumanaChoice Giveback H5525-035 (PPO) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
HumanaChoice H5525-049 (PPO) Tier 4 - Non-Preferred — — ✓ 90 per 30 days QL
Alignment Health AVA (PPO) Tier 5 - Specialty ✓ — — PA
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 5 - Specialty ✓ — — PA
Alignment Health Platinum Select (HMO) Tier 5 - Specialty ✓ — — PA
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 5 - Specialty ✓ — — PA
Alignment Health smartHMO (HMO) Tier 5 - Specialty ✓ — — PA
Alignment Health NC Duals (HMO-POS D-SNP) Tier 5 - Specialty ✓ — — PA
Alignment Health Platinum (HMO) Tier 5 - Specialty ✓ — — PA
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 12 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026 Not Covered — — — None
NC State Health Plan - 70/30 Standard PPO 2026 Not Covered — — — None
NC State Health Plan - 80/20 Plus PPO 2026 Not Covered — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 12 hours, 52 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UnitedHealthcare NC Individual & Family 2026 Tier 3 - Mid-Range Cost — — — None
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