mafenide

50 MG

Methylated Sulfonamide Antibacterial

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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: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 17 hours, 31 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Focused Silver with Atrium Health Tier 4 - Non-Preferred — — — None
Standard Expanded Bronze with Atrium Health Tier 4 - Non-Preferred — — — None
Standard Silver with Atrium Health Tier 4 - Non-Preferred — — — None
Standard Gold with Atrium Health Tier 4 - Non-Preferred — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Complete Gold + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Everyday Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Elite Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Focused Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Complete Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Everyday Bronze
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Standard Expanded Bronze + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Standard Silver + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Standard Gold + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Standard Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Elite Bronze
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Clear Silver with $0 Insulin Options
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Standard Expanded Bronze
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Standard Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred — — — None
Standard Silver
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Standard Gold
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Complete Gold + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Everyday Bronze with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Elite Bronze with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Everyday Bronze + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Elite Bronze + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Focused Silver with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Complete Gold with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Standard Expanded Bronze with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Standard Silver with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Standard Gold with Atrium Health
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Standard Expanded Bronze + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Standard Silver + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Standard Gold + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Standard Silver Tier 4 - Non-Preferred — — — None
Standard Gold Tier 4 - Non-Preferred — — — None
Everyday Bronze with Atrium Health Tier 4 - Non-Preferred — — — None
Elite Bronze with Atrium Health Tier 4 - Non-Preferred — — — None
Complete Gold with Atrium Health Tier 4 - Non-Preferred — — — None
Complete Gold
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Complete Gold Tier 4 - Non-Preferred — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 4 - Non-Preferred — — — None
Everyday Bronze Tier 4 - Non-Preferred — — — None
Elite Bronze Tier 4 - Non-Preferred — — — None
Clear Silver with $0 Insulin Options Tier 4 - Non-Preferred — — — None
Standard Expanded Bronze Tier 4 - Non-Preferred — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 17 hours, 31 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Care 2026
via Sulfamylon 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Value 2026
via Sulfamylon 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Advantage 2026
via Sulfamylon 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Home with UNC Health Alliance 2026
via Sulfamylon 		Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Local 2026
via Sulfamylon 		Tier 4 - Higher Cost Brand — — — Restricted Access None
Source: CMS QHP JSON  ·  Formulary date: Mar 18, 2026  ·  Checked: 17 hours, 31 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
DEVOTED CHOICE 003 NC (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
Aetna Medicare Signature (HMO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Dual (HMO D-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Value Plus (HMO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Prime (HMO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Care (HMO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (HMO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Extra (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Giveback (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — — None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED DUAL 009 NC (HMO D-SNP)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED CORE 001 NC (HMO)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED GIVEBACK 002 NC (HMO)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED GIVEBACK 012 NC (HMO)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED CHOICE 001 NC (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED CHOICE 005 NC (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED CHOICE 008 NC (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via Sulfamylon 		Tier 4 - Non-Preferred — — ✓ 453.6 per 30 days QL
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 17 hours, 31 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UnitedHealthcare NC Individual & Family 2026
via Sulfamylon 		Tier 4 - Higher Cost — — — None
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