TETRACAINE

0.5%

Ester Local Anesthetic

GoodRx Compare Prices

Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: PDF  ·  Formulary date: Oct 15, 2026  ·  Checked: 15 hours, 40 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Bronze RD CMS Standard
via Altacaine 		Tier 2 - Generic — — — None
Connect Silver RD CMS Standard
via Altacaine 		Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible
via Altacaine 		Tier 2 - Generic — — — None
Connect Gold RD CMS Standard
via Altacaine 		Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible
via Altacaine 		Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 3600 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze CMS Standard Tier 2 - Generic — — — None
Connect Silver CMS Standard Tier 2 - Generic — — — None
Connect Gold CMS Standard Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze Tier 2 - Generic — — — None
Connect myDiabetesCare Silver Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD CMS Standard Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Gold RD CMS Standard Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible
via Altacaine 		Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible
via Altacaine 		Tier 2 - Generic — — — None
Connect Silver 5000 Indiv Med Deductible
via Altacaine 		Tier 2 - Generic — — — None
Connect Silver 3600 Indiv Med Deductible
via Altacaine 		Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible
via Altacaine 		Tier 2 - Generic — — — None
Connect Bronze CMS Standard
via Altacaine 		Tier 2 - Generic — — — None
Connect Silver CMS Standard
via Altacaine 		Tier 2 - Generic — — — None
Connect Gold CMS Standard
via Altacaine 		Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze
via Altacaine 		Tier 2 - Generic — — — None
Connect myDiabetesCare Silver
via Altacaine 		Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible
via Altacaine 		Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible
via Altacaine 		Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible
via Altacaine 		Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible
via Altacaine 		Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible
via Altacaine 		Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 15 hours, 40 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 80/20 Plus PPO 2026
via Altacaine 		Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Altacaine 		Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - HDHP 2026
via Altacaine 		Tier 3 - Non-Preferred Brand — — — None
NC State Health Plan - HDHP 2026
via Pliaglis 		Not Covered — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Pliaglis 		Not Covered — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Pliaglis 		Not Covered — — — None
Source: Excel (XLSX)  ·  Formulary date: Sep 23, 2026  ·  Checked: 15 hours, 40 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026
via Pliaglis 		Tier 2 - Brand Formulary ✓ — ✓ PLIAGLIS, LIDOCAINE-TETRACAINE CREAM LTD TO A MAX QTY OF 60 GRAMS PER DISPENSING AT RETAIL OR MAIL PA | QL PA: TPA - LIDOCAINE-TETRACAINE, TOPICAL PLIAGLIS CREAM (GRAM) FOR PT >12YRS REQUIRES PRIOR AUTHORIZATION; Quantity limit
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 15 hours, 40 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals)
via Altacaine 		Tier 1 - Preferred Generic — — — None
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Altacaine 		Tier 1 - Preferred Generic — — — None
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals)
via Altacaine 		Tier 1 - Preferred Generic — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Altacaine 		Tier 1 - Preferred Generic — — — None
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Altacaine 		Tier 1 - Preferred Generic — — — None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals)
via Altacaine 		Tier 1 - Preferred Generic — — — None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals)
via Altacaine 		Tier 1 - Preferred Generic — — — None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Altacaine 		Tier 1 - Preferred Generic — — — None
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals)
via Altacaine 		Tier 1 - Preferred Generic — — — None
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via Altacaine 		Tier 1 - Preferred Generic — — — None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals)
via Altacaine 		Tier 1 - Preferred Generic — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via Altacaine 		Tier 1 - Preferred Generic — — — None
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals)
via Altacaine 		Tier 1 - Preferred Generic — — — None
UHC Bronze Standard (HSA, $0 Insulin, No Referrals)
via Altacaine 		Tier 1 - Preferred Generic — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via Altacaine 		Tier 1 - Preferred Generic — — — None
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via Altacaine 		Tier 1 - Preferred Generic — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Altacaine 		Tier 1 - Preferred Generic — — — None
Something not right?