Lithostat

Generic: acetohydroxamic acid

250 Mg — Tablet

VAGINAL PRODUCTS

Also known as: LITHOSTAT TABS 250MG Lithostat 250 Mg Tablet
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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.
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 15 hours, 21 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Standard Option 2026 Tier 3 - Non-Preferred Brand — — — None
BCBS Federal Basic Option 2026 Tier 3 - Non-Preferred Brand — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 15 hours, 21 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Advantage 2026 Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Local 2026 Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Care 2026 Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Value 2026 Tier 4 - Higher Cost Brand — — — Restricted Access None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 15 hours, 21 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Bronze CMS Standard Tier 4 - Non-Preferred — — — None
Connect Gold CMS Standard Tier 4 - Non-Preferred — — — None
Connect Bronze RD CMS Standard Tier 4 - Non-Preferred — — — None
Connect Gold RD CMS Standard Tier 4 - Non-Preferred — — — None
Connect myDiabetesCare Silver Tier 4 - Non-Preferred — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Gold 1500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect myDiabetesCare Bronze Tier 4 - Non-Preferred — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze RD 6000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver 3500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze RD 5000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver RD 3500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze 7000 HSA Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver 4400 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver RD 5000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver 3000 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Bronze 6500 Indiv Med Deductible Tier 4 - Non-Preferred — — — None
Connect Silver CMS Standard Tier 4 - Non-Preferred — — — None
Connect Silver RD CMS Standard Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 15 hours, 21 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 70/30 Standard PPO 2026 Not Covered — — — None
NC State Health Plan - HDHP 2026 Not Covered — — — None
NC State Health Plan - 80/20 Plus PPO 2026 Not Covered — — — None
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