etripamil

70 mg/2 spray — Spray

Also known as: CARDAMYST

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

3 plans

Source: CMS QHP JSON · Formulary date: Jun 10, 2026 · Checked: 2 hours, 15 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Troy Medicare (HMO) via Cardamyst	Tier 5 - Specialty	✓	—	✓ 4 per 30 days	PA \| QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Cardamyst	Tier 5 - Specialty	✓	—	✓ 4 per 30 days	PA \| QL
AmeriHealth Caritas VIP Care (HMO D-SNP) via Cardamyst	Tier 5 - Specialty	✓	—	✓ 4 per 30 days	PA \| QL

1 plan

Source: Excel (XLSX) · Formulary date: Jun 24, 2026 · Checked: 2 hours, 15 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 3 - Non-Formulary	✓	—	—	PA