Fragmin
Generic: dalteparin sodium
10000UNIT/4ML, 95000UNIT/3.8ML — Prefilled Syringe
Also known as:
FRAGMIN SOLN 10000UNIT/4ML, 95000UNIT/3.8ML; SOSY 2500UNIT/0.2ML, 5000UNIT/0.2ML, 7500UNIT/0.3ML, 10000UNIT/ML, 12500UNIT/0.5ML, 15000UNIT/0.6ML, 18000UNT/0.72ML
dalteparin sodium
FRAGMIN SOSY 5000UNIT/0.2ML, 10000UNIT/ML, 15000UNIT/0.6ML, 18000UNT/0.72ML
FRAGMIN SOLN 10000UNIT/4ML,
Fragmin Subcutaneous Solution Prefilled Syringe
Dalteparin Sodium
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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.
Ambetter (Centene)
29 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Complete Gold with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Expanded Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Silver + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Gold + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Silver with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Gold with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Gold | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Silver | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Expanded Bronze | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Clear Silver with $0 Insulin Options | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Focused Silver with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Expanded Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Silver with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Standard Gold with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Focused Silver with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
AmeriHealth Caritas NC
10 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Bronze Essential + No Referrals | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| AmeriHealth Caritas Next Gold Premier + No Referrals | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| AmeriHealth Caritas Next Silver Essential + No Referrals | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| AmeriHealth Caritas Next Bronze Premier + No Referrals | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| AmeriHealth Caritas Next Gold Signature + No Referrals | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| AmeriHealth Caritas Next Silver Signature + No Referrals | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| AmeriHealth Caritas Next Bronze Signature + No Referrals | Tier 4 - Non-Preferred | — | — | ✓ | QL |
Blue Cross Blue Shield Federal
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBS Federal Standard Option 2026 | Tier 2 - Preferred Brand | — | — | — | None |
| BCBS Federal Focus 2026 | Tier 2 - Preferred Brand | — | — | — | None |
| BCBS Federal Basic Option 2026 | Tier 2 - Preferred Brand | — | — | — | None |
Blue Cross Blue Shield of NC
5 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBSNC Blue Local 2026 | Tier 4 - Higher Cost Brand | — | — | — | None |
| BCBSNC Blue Home with UNC Health Alliance 2026 | Tier 4 - Higher Cost Brand | — | — | — | None |
| BCBSNC Blue Advantage 2026 | Tier 4 - Higher Cost Brand | — | — | — | None |
| BCBSNC Blue Value 2026 | Tier 4 - Higher Cost Brand | — | — | — | None |
| BCBSNC Blue Care 2026 | Tier 4 - Higher Cost Brand | — | — | — | None |
Cigna
20 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Connect Silver 3000 Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect myDiabetesCare Silver | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Silver RD 2200 Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Gold 1500 Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect myDiabetesCare Bronze | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Bronze 5500 Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Bronze RD 6000 Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Silver 3500 Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Bronze RD 5000 Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Silver RD 3500 Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Bronze 7000 HSA Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Silver 4400 Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Silver RD 5000 Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Bronze 6500 Indiv Med Deductible | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Silver CMS Standard | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Silver RD CMS Standard | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Gold CMS Standard | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Bronze RD CMS Standard | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Gold RD CMS Standard | Tier 5 - Specialty | — | — | ✓ | QL |
| Connect Bronze CMS Standard | Tier 5 - Specialty | — | — | ✓ | QL |
Medicare Part D
25 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature Extra (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Full Dual Care (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature Care (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Prime (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Value Plus (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Dual (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Enhanced (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Enhanced (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Enhanced (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Chronic Care (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature Giveback (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HealthTeam Advantage Plan I (PPO) | Tier 5 - Specialty | — | — | — | None |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 5 - Specialty | — | — | — | None |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 5 - Specialty | — | — | — | None |
| HealthTeam Advantage Plan II (PPO) | Tier 5 - Specialty | — | — | — | None |
NC Medicaid PDL
1 planNC State Health Plan
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| NC State Health Plan - 70/30 Standard PPO 2026 | Tier 3 - Non-Preferred Brand | — | — | — | None |
| NC State Health Plan - HDHP 2026 | Tier 3 - Non-Preferred Brand | — | — | — | None |
| NC State Health Plan - 80/20 Plus PPO 2026 | Tier 3 - Non-Preferred Brand | — | — | — | None |
Oscar Health
28 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Silver Classic | Tier 4 - Non-Preferred | — | — | — | None |
| Secure | Tier 4 - Non-Preferred | — | — | — | None |
| Bronze Classic 4700 | Tier 4 - Non-Preferred | — | — | — | None |
| Silver Simple PCP Saver | Tier 4 - Non-Preferred | — | — | — | None |
| Gold Elite Saver Plus | Tier 4 - Non-Preferred | — | — | — | None |
| Silver Simple Diabetes | Tier 4 - Non-Preferred | — | — | — | None |
| Secure | with Atrium Health | Tier 4 - Non-Preferred | — | — | — | None |
| Bronze Classic 4700 | with Atrium Health | Tier 4 - Non-Preferred | — | — | — | None |
| Bronze Elite + PCP Saver Plus | with Atrium Health | Tier 4 - Non-Preferred | — | — | — | None |
| Silver Classic | with Atrium Health | Tier 4 - Non-Preferred | — | — | — | None |
| Silver Simple Diabetes | with Atrium Health | Tier 4 - Non-Preferred | — | — | — | None |
| Silver Simple PCP Saver | with Atrium Health | Tier 4 - Non-Preferred | — | — | — | None |
| Gold Elite Saver Plus | with Atrium Health | Tier 4 - Non-Preferred | — | — | — | None |
| Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 4 - Non-Preferred | — | — | — | None |
| Bronze Simple Chronic Care CKM | with Atrium Health | Tier 4 - Non-Preferred | — | — | — | None |
| Bronze Simple Diabetes | with Atrium Health | Tier 4 - Non-Preferred | — | — | — | None |
| Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 4 - Non-Preferred | — | — | — | None |
| Silver Simple Chronic Care CKM | with Atrium Health | Tier 4 - Non-Preferred | — | — | — | None |
| Silver Simple Women's Health with Menopause Benefits | with Atrium Health | Tier 4 - Non-Preferred | — | — | — | None |
| AIAN Cost Share | Tier 4 - Non-Preferred | — | — | — | None |
| AIAN Cost Share | with Atrium Health | Tier 4 - Non-Preferred | — | — | — | None |
| Bronze Classic Standard | Tier 4 - Non-Preferred | — | — | — | None |
| Silver Classic Standard | Tier 4 - Non-Preferred | — | — | — | None |
| Gold Classic Standard | Tier 4 - Non-Preferred | — | — | — | None |
| Bronze Classic Standard | with Atrium Health | Tier 4 - Non-Preferred | — | — | — | None |
| Silver Classic Standard | with Atrium Health | Tier 4 - Non-Preferred | — | — | — | None |
| Gold Classic Standard | with Atrium Health | Tier 4 - Non-Preferred | — | — | — | None |
| Bronze Elite + PCP Saver Plus | Tier 4 - Non-Preferred | — | — | — | None |
UnitedHealthcare
13 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Gold Standard (No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Bronze Standard (No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Silver Value ($0 Virtual Urgent Care, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Silver Standard (No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Bronze Standard+ Dental + Vision (No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |
| UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 4 - Non-Preferred | — | — | ✓ | QL |