Orlynvah

Generic: sulopenem etzadroxil/probenecid

500-500 MG — Tablet

Also known as: ORLYNVAH TAB 500-500

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

2 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 18 hours, 53 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Standard Option 2026	Tier 3 - Non-Preferred Brand	✓	—	—	PA
BCBS Federal Basic Option 2026	Tier 3 - Non-Preferred Brand	✓	—	—	PA

1 plan

Source: Excel (XLSX) · Formulary date: Oct 29, 2026 · Checked: 18 hours, 52 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 2 - Brand Formulary	—	✓	✓ ORLYNVAH TO BE DISPENSED AT A MAXIMUM QUANTITY OF 10 TABLETS PER DISP AT RETAIL OR MAIL	ST \| QL Step therapy: ORLYNVAH FOR PATIENTS <18 YEARS OF AGE REQUIRES PRIOR AUTHORIZATION; Quantity limit