Omnipod 5 G6-G7 Intro KT(GEN5)

STR N/A — Device

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: 7 hours, 10 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 2 - Brand Formulary	✓	—	✓ OMNIPOD 5 G6 INTRO KIT (GEN 5) TO BE DISP AT A MAXIMUM QUANTITY OF 1 KIT IN 720 DAYS	PA \| QL PA: 1270/48001/90693 PA DRUGS, DOD PA REQUIRED; Quantity limit on 1 of 2 NDCs