Olmesartan-Amlodipine-Hctz

Generic: olmesartan medoxomil/amlodipine besylate/hydrochlorothiazide

40-10-12.5 Mg — Tablet

Angiotensin Ii Receptor Blocker Combinations

Also known as: Tribenzor Olmesartan-Amlodipine-Hctz 20-5-12.5 Mg Tablet Olmesartan-Amlodipine-Hctz 40-10-12.5 Mg Tablet Olmesartan-Amlodipine-Hctz 40-10-25 Mg Tablet Olmesartan-Amlodipine-Hctz 40-5-12.5 Mg Tablet Olmesartan-Amlodipine-Hctz 40-5-25 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.

Blue Cross Blue Shield Federal

2 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 10 hours, 59 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Basic Option 2026 via Tribenzor	Tier 3 - Non-Preferred Brand	—	—	—	None
BCBS Federal Standard Option 2026 via Tribenzor	Tier 3 - Non-Preferred Brand	—	—	—	None

Blue Cross Blue Shield of NC

5 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 10 hours, 59 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBSNC Blue Local 2026 via Tribenzor	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Care 2026 via Tribenzor	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Value 2026 via Tribenzor	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Advantage 2026 via Tribenzor	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026 via Tribenzor	Tier 2 - Medium Cost Generic/Brand	—	—	—	None

Cigna

1 plan

Source: PDF · Formulary date: Jan 1, 2026 · Checked: 10 hours, 59 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Cigna Plus NC 4-Tier Formulary 2026	Tier 1 - Generic	—	—	—	None

NC Medicaid PDL

2 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 10 hours, 59 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC Medicaid Preferred Drug List 2026	Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026 via Tribenzor	Non-Preferred	—	—	—	None

NC State Health Plan

3 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 10 hours, 59 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - 70/30 Standard PPO 2026 via Tribenzor	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Tribenzor	Tier 3 - Non-Preferred Brand	—	—	—	None
NC State Health Plan - HDHP 2026 via Tribenzor	Tier 3 - Non-Preferred Brand	—	—	—	None

TRICARE

1 plan

Source: Excel (XLSX) · Formulary date: Jan 5, 2026 · Checked: 10 hours, 59 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026 via olmesartan medoxomil/amlodipine besylate/hydrochlorothiazide	Tier 3 - Non-Formulary	✓	—	—	PA