sulfacetamide sodium-sulfur

10 %-2 %, 10-5%(W/W), 8 %-4 %, 9 %-4.5 % — LOTION (GRAM)

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: 7 hours, 11 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 1 - Generic Formulary	✓	—	—	PA PA on 5 of 7 NDCs: 1270/48001/90693 PA DRUGS, DOD PA REQUIRED