Tri-mix (PAPVRN-PHNTLMN-PGE1)

150-5-50 — VIAL (EA)

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: Oct 29, 2026 · Checked: 5 hours, 22 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 2 - Brand Formulary	—	—	✓ EBD: IMPOTENCE - INJECTABLE: TIERED QUANTITY	QL Quantity limit