Promacta Pack

12.5MG, 25MG — Tablet

Also known as: PROMACTA PACK 12.5MG, 25MG; TABS 12.5MG, 25MG, 50MG, 75MG PROMACTA PACK 12.5MG, 25MG; TABS

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

2 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 17 hours, 35 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Standard Option 2026	Tier 5 - Non-Preferred Specialty	✓	—	—	PA
BCBS Federal Basic Option 2026	Tier 5 - Non-Preferred Specialty	✓	—	—	PA

3 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 17 hours, 35 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - 80/20 Plus PPO 2026	Tier 5 - Preferred Brand Specialty	✓	—	✓	PA \| QL
NC State Health Plan - 70/30 Standard PPO 2026	Tier 5 - Preferred Brand Specialty	✓	—	✓	PA \| QL
NC State Health Plan - HDHP 2026	Tier 5 - Preferred Brand Specialty	✓	—	✓	PA \| QL