Omnipod 5 Intro (LIBRE2/3PLUS)

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, 8 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 2 - Brand Formulary	✓	—	✓ OMNIPOD 5 INTRO (LIBRE2/3PLUS) TO BE DISP AT A MAX QTY OF 1 KIT IN 540 DAYS	PA \| QL PA: 1270/48001/90693 PA DRUGS, DOD PA REQUIRED; Quantity limit