Perio Med

Generic: stannous fluoride

6.3 MG

Also known as: stannous fluoride
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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 9 hours, 32 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Standard Gold with Atrium Health + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Standard Silver + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Standard Gold + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Standard Silver with Atrium Health + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Complete Gold
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Everyday Bronze
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Elite Bronze
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Clear Silver with $0 Insulin Options
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Standard Silver
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Standard Gold
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Everyday Bronze with Atrium Health
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Elite Bronze with Atrium Health
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Focused Silver with Atrium Health
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Complete Gold with Atrium Health
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze with Atrium Health
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Standard Silver with Atrium Health
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Standard Gold with Atrium Health
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Complete Gold + Vision + Adult Dental
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Everyday Bronze + Vision + Adult Dental
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Elite Bronze + Vision + Adult Dental
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze + Vision + Adult Dental
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Standard Silver + Vision + Adult Dental
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Standard Gold + Vision + Adult Dental
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Standard Silver with Atrium Health + Vision + Adult Dental
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Standard Gold with Atrium Health + Vision + Adult Dental
via stannous fluoride 		Tier 0 - $0 Preventive — — — None
Complete Gold Tier 0 - $0 Preventive — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 0 - $0 Preventive — — — None
Everyday Bronze Tier 0 - $0 Preventive — — — None
Elite Bronze Tier 0 - $0 Preventive — — — None
Clear Silver with $0 Insulin Options Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze Tier 0 - $0 Preventive — — — None
Standard Silver Tier 0 - $0 Preventive — — — None
Standard Gold Tier 0 - $0 Preventive — — — None
Everyday Bronze with Atrium Health Tier 0 - $0 Preventive — — — None
Elite Bronze with Atrium Health Tier 0 - $0 Preventive — — — None
Focused Silver with Atrium Health Tier 0 - $0 Preventive — — — None
Complete Gold with Atrium Health Tier 0 - $0 Preventive — — — None
Standard Expanded Bronze with Atrium Health Tier 0 - $0 Preventive — — — None
Standard Silver with Atrium Health Tier 0 - $0 Preventive — — — None
Standard Gold with Atrium Health Tier 0 - $0 Preventive — — — None
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Complete Gold + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Everyday Bronze + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Elite Bronze + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Focused Silver with Atrium Health + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Complete Gold with Atrium Health + Vision + Adult Dental Tier 0 - $0 Preventive — — — None
Source: PDF  ·  Formulary date: Apr 1, 2026  ·  Checked: 9 hours, 32 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Home with UNC Health Alliance 2026
via Easygel 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 2026
via Easygel 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026
via Easygel 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Value 2026
via Easygel 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Advantage 2026
via Easygel 		Tier 1 - Lowest Cost Generic — — — None
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