prenatal plus dha

28-800-200, 28-975-200 — COMBINATION PACKAGE (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: 5 hours, 29 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 1 - Generic Formulary	—	—	✓ SEL TEST STRIPS TO DISP AT MAX OF 100 UNITS IN 22D OR 300 UNITS IN 68D W/O QF IN 365D OR RX BY OBGYN	QL Quantity limit