theophylline anhydrous

200 mg, 300 mg, 400 mg, 80 mg/15 mL, 80 mg/15 mL (15 mL) — Elixir

Also known as: THEOPHYLLINE THEO-24 THEOPHYLLINE ER ELIXOPHYLLIN

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: Jan 5, 2026 · Checked: 22 hours, 26 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 1 - Basic Core Formulary	—	—	—	None