nutritional therapy for phenylketonuria(PKU) with iron no.30

62.2 gram-294 kcal/100 gram — Pack

Also known as: PKU GOLIKE PLUS (4-16 YR)

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: Jan 5, 2026 · Checked: 11 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 3 - Non-Formulary	—	—	—	None