Osmolex

Generic: amantadine

129MG, 193MG, 258MG — Extended Release Tablet

Also known as: OSMOLEX ER TB24 129MG, 193MG, 258MG OSMOLEX ER TB24 193MG

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

1 plan

Source: PDF · Formulary date: Jan 1, 2026 · Checked: 20 hours, 50 minutes ago

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

3 plans

Source: CMS QHP JSON · Formulary date: Mar 18, 2026 · Checked: 20 hours, 50 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Troy Medicare (HMO) via Gocovri	Tier 5 - Specialty	✓	—	—	PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Gocovri	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas VIP Care (HMO D-SNP) via Gocovri	Tier 5 - Specialty	✓	—	✓ 60 per 30 days	PA \| QL

3 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 20 hours, 50 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC Medicaid Preferred Drug List 2026 via Gocovri	Non-Preferred	✓	—	—	PA
NC Medicaid Preferred Drug List 2026	Non-Preferred	✓	—	—	PA
NC Medicaid Preferred Drug List 2026 via Amantadine	Non-Preferred	✓	—	—	PA