Pretomanid

200 MG — Tablet

FLUOROQUINOLONES

Also known as: PRETOMANID TABS 200MG Pretomanid Oral Tablet
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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, 3 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Signature Gold Tier 4 - Non-Preferred ✓ — — PA
Signature Silver + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Signature Gold + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Signature Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Signature Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Clear Silver with $0 Insulin Options Tier 4 - Non-Preferred ✓ — — PA
Signature Expanded Bronze Tier 4 - Non-Preferred ✓ — — PA
Signature Silver Tier 4 - Non-Preferred ✓ — — PA
Focused Silver with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Complete Gold with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Complete Gold Tier 4 - Non-Preferred ✓ — — PA
Enhanced Asthma/COPD Care Silver $0 Rx Options Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze Tier 4 - Non-Preferred ✓ — — PA
Clear Silver with $0 Insulin Options + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze Tier 4 - Non-Preferred ✓ — — PA
Streamlined Silver Tier 4 - Non-Preferred ✓ — — PA
Streamlined Silver with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Enhanced CHF Heart Care Silver $0 Rx Options Tier 4 - Non-Preferred ✓ — — PA
Signature Expanded Bronze + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Focused Silver with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Complete Gold with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Signature Expanded Bronze with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Signature Silver with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Signature Gold with Atrium Health Tier 4 - Non-Preferred ✓ — — PA
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Complete Gold + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 4 - Non-Preferred ✓ — — PA
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 9 hours, 3 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic ✓ — — PA
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 4 - Non-Preferred ✓ — — PA
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 9 hours, 3 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Standard Option 2026 Tier 2 - Preferred Brand — — — None
BCBS Federal Focus 2026 Tier 2 - Preferred Brand — — — None
BCBS Federal Basic Option 2026 Tier 2 - Preferred Brand — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 9 hours, 3 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 3 - High Cost Brand — — — Limited Distribution None
BCBSNC Blue Advantage 2026 Tier 3 - High Cost Brand — — — Limited Distribution None
BCBSNC Blue Local 2026 Tier 3 - High Cost Brand — — — Limited Distribution None
BCBSNC Blue Care 2026 Tier 3 - High Cost Brand — — — Limited Distribution None
BCBSNC Blue Value 2026 Tier 3 - High Cost Brand — — — Limited Distribution None
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 9 hours, 3 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Alignment Health Platinum Select (HMO) Tier 4 - Non-Preferred — — — None
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Extra (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Giveback (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Alignment Health AVA (PPO) Tier 4 - Non-Preferred — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Alignment Health Platinum (HMO) Tier 4 - Non-Preferred — — — None
Blue Medicare Enhanced (HMO-POS) Tier 4 - Non-Preferred — — — None
Blue Medicare Essential Plus (HMO-POS) Tier 4 - Non-Preferred — — — None
Blue Medicare PPO Enhanced (PPO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Blue Medicare Essential (HMO) Tier 4 - Non-Preferred — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Alignment Health NC Duals (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Alignment Health smartHMO (HMO) Tier 4 - Non-Preferred — — — None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Blue Medicare Choice (HMO) Tier 4 - Non-Preferred — — — None
Troy Medicare (HMO) Tier 4 - Non-Preferred ✓ — — PA
Experience Health Medicare Advantage (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 30 per 30 days PA | QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 9 hours, 3 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 70/30 Standard PPO 2026 Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - HDHP 2026 Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 80/20 Plus PPO 2026 Tier 3 - Non-Preferred Brand — — — None
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