Triptodur

Generic: triptorelin

22.5 MG

Also known as: triptorelin
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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 6 hours, 39 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Everyday Bronze + Vision + Adult Dental
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Everyday Bronze with Atrium Health
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Elite Bronze with Atrium Health
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Focused Silver with Atrium Health
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Complete Gold with Atrium Health
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Standard Expanded Bronze with Atrium Health
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Standard Silver with Atrium Health
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Standard Gold with Atrium Health
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Complete Gold + Vision + Adult Dental
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Everyday Bronze
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Elite Bronze + Vision + Adult Dental
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Elite Bronze with Atrium Health + Vision + Adult Dental
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Complete Gold
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Standard Gold with Atrium Health + Vision + Adult Dental
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Standard Silver with Atrium Health + Vision + Adult Dental
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Standard Gold + Vision + Adult Dental
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Standard Silver + Vision + Adult Dental
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Standard Expanded Bronze + Vision + Adult Dental
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Complete Gold with Atrium Health + Vision + Adult Dental
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Focused Silver with Atrium Health + Vision + Adult Dental
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Standard Gold
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Standard Silver
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Standard Expanded Bronze
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Clear Silver with $0 Insulin Options
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Elite Bronze
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Source: CMS QHP JSON  ·  Checked: 6 hours, 39 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Bronze Signature + No Referrals
via Trelstar 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Premier + No Referrals
via Trelstar 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Essential + No Referrals
via Trelstar 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Premier + No Referrals
via Trelstar 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Premier + No Referrals
via Trelstar 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via Trelstar 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Gold Signature + No Referrals
via Trelstar 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Signature + No Referrals
via Trelstar 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Bronze Essential + No Referrals
via Trelstar 		Tier 5 - Specialty ✓ — — PA
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via Trelstar 		Tier 5 - Specialty ✓ — — PA
Source: CMS QHP JSON  ·  Formulary date: May 13, 2026  ·  Checked: 6 hours, 39 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Longevity Health Plan (HMO I-SNP)
via Trelstar 		Tier 1 - Preferred Generic ✓ — — PA
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via Trelstar 		Tier 1 - Preferred Generic ✓ — ✓ 1 per 168 days PA | QL
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Trelstar 		Tier 1 - Preferred Generic ✓ — ✓ 1 per 168 days PA | QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via Trelstar 		Tier 1 - Preferred Generic ✓ — ✓ 1 per 168 days PA | QL
NHC Advantage (HMO I-SNP)
via Trelstar 		Tier 1 - Preferred Generic — — ✓ 1 per 168 days QL
PruittHealth Premier (HMO I-SNP)
via Trelstar 		Tier 1 - Preferred Generic — — ✓ 1 per 168 days QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via Trelstar 		Tier 1 - Preferred Generic — — ✓ 1 per 168 days QL
Liberty Medicare Dual Plan (HMO D-SNP)
via Trelstar 		Tier 1 - Preferred Generic — — ✓ 1 per 168 days QL
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
HealthSpring True Choice (PPO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
HealthSpring TotalCare (HMO D-SNP)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
HealthSpring TotalCare Plus (HMO D-SNP)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
HealthSpring Preferred (HMO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
HealthSpring Preferred Select (HMO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
HealthSpring Preferred Savings (HMO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
HealthSpring Preferred Plus (HMO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Liberty Medicare Advantage (HMO C-SNP)
via Trelstar 		Tier 4 - Non-Preferred — — ✓ 1 per 168 days QL
Blue Medicare PPO Enhanced (PPO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Blue Medicare Essential Plus (HMO-POS)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Blue Medicare Enhanced (HMO-POS)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Blue Medicare Choice (HMO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Blue Medicare Essential (HMO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Experience Health Medicare Advantage (HMO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Healthy Blue + Medicare (HMO-POS D-SNP)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Troy Medicare (HMO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus H1036-137 (HMO-POS)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus H1036-233 (HMO-POS)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Humana Dual Select H1036-307 (HMO D-SNP)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus H1036-335 (HMO-POS)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
HumanaChoice Giveback H5216-017 (PPO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
HumanaChoice H5216-211 (PPO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Humana Full Access H5525-034 (PPO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
HumanaChoice Giveback H5525-035 (PPO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
HumanaChoice H5525-049 (PPO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
HumanaChoice H5525-050 (PPO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
HumanaChoice H5525-070 (PPO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Humana Dual Select H5525-072 (PPO D-SNP)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
HumanaChoice H5525-083 (PPO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus H6622-025 (HMO-POS)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus H6622-026 (HMO-POS)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus H6622-057 (HMO-POS)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus H6622-060 (HMO-POS)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus H6622-061 (HMO-POS)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Choice H8145-004 (PFFS)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Senior Care (HMO I-SNP)
via Trelstar 		Tier 4 - Non-Preferred — — ✓ 1 per 168 days QL
Alignment Health Platinum (HMO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Alignment Health NC Duals (HMO-POS D-SNP)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Alignment Health smartHMO (HMO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Alignment Health Platinum Select (HMO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
Alignment Health AVA (PPO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — — PA
HealthTeam Advantage Plan I (PPO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — ✓ 1 per 168 days PA | QL
HealthTeam Advantage Plan II (PPO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — ✓ 1 per 168 days PA | QL
HealthTeam Advantage Vitality Plan (PPO)
via Trelstar 		Tier 4 - Non-Preferred ✓ — ✓ 1 per 168 days PA | QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Trelstar 		Tier 4 - Non-Preferred ✓ — ✓ 1 per 168 days PA | QL
Source: CMS QHP JSON  ·  Checked: 6 hours, 39 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AIAN Cost Share | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
AIAN Cost Share Tier 5 - Specialty ✓ — ✓ PA | QL
Secure | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Elite Saver Plus Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic Standard | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Classic Standard Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic Standard Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic Standard Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic 4700 Tier 5 - Specialty ✓ — ✓ PA | QL
Secure Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple PCP Saver Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Classic Standard | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic Standard | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Chronic Care CKM | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Diabetes | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Chronic Care CKM | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Gold Elite Saver Plus | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple PCP Saver | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Simple Diabetes | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Silver Classic | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
Bronze Classic 4700 | with Atrium Health Tier 5 - Specialty ✓ — ✓ PA | QL
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