Hydrocodone Polistirex/ Ch

Generic: hydrocod polst-chlorphen polst

COUGH/COLD/ALLERGY

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 1, 2026  ·  Checked: 9 hours, 58 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Focus 2026
via hydrocod polst-chlorphen polst
Tier 1 - Generic — — ✓ QL
BCBS Federal Basic Option 2026
via hydrocod polst-chlorphen polst
Tier 1 - Generic — — ✓ QL
BCBS Federal Standard Option 2026
via hydrocod polst-chlorphen polst
Tier 1 - Generic — — ✓ QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 9 hours, 58 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Care 2026 Tier 4 - Higher Cost Brand — — — None
BCBSNC Blue Value 2026 Tier 4 - Higher Cost Brand — — — None
BCBSNC Blue Advantage 2026 Tier 4 - Higher Cost Brand — — — None
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 4 - Higher Cost Brand — — — None
BCBSNC Blue Local 2026 Tier 4 - Higher Cost Brand — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 9 hours, 58 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026
via hydrocod polst-chlorphen polst
Tier 1 - Preferred Generic ✓ — — PA
NC State Health Plan - 70/30 Standard PPO 2026
via hydrocod polst-chlorphen polst
Tier 1 - Preferred Generic ✓ — — PA
NC State Health Plan - 80/20 Plus PPO 2026
via hydrocod polst-chlorphen polst
Tier 1 - Preferred Generic ✓ — — PA
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