Omnipod Dash Pods (gen 4)

STR N/A — CARTRIDGE (EA)

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: 8 hours, 58 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 2 - Brand Formulary	✓	—	✓ OMNIPOD/DASH/CLASSIC PODS/(GEN3)/(GEN 4) LTD TO MAX QTY OF 15PODS PER DISP AT RTL OR 45PODS AT MAIL	PA \| QL PA: 1270/48001/90693 PA DRUGS, DOD PA REQUIRED; Quantity limit