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0.15MG(84), 100-20(84), 150-30(84) — TABLET, DOSE PACK, 3 MONTHS

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: 5 hours, 30 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 1 - Generic Formulary	—	—	✓ 1270/48001/44029&43753 EBD: CONT - NON-INJ 90 DAY, MO/EBD: CONT - NON-INJ 90 DAY: QUANTITY DQL	QL Quantity limit