esmolol hcl-sodium chloride

2000MG/100, 2500MG/250 — INTRAVENOUS SOLUTION

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

1 plan

Source: Excel (XLSX) · Formulary date: Sep 23, 2026 · Checked: 7 hours, 59 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 1 - Generic Formulary	✓	—	—	PA PA: TPA - ALDACTONE TABLET FOR MALE PTS 11 THRU 18 YRS OF AGE W/O QUALIFIERS IN 360 DAYS REQ PA