triprolidine HCl/pseudoephedrine HCl/dextromethorphan HBr

2.5 mg-30 mg-20 mg/5 mL — Liquid

Also known as: HISTEX-DM

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: 4 hours, 54 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 3 - Non-Formulary	—	—	—	None