Trudhesa

Generic: dihydroergotamine mesylate

0.725/SPRY — Spray

MIGRAINE AGENTS

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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: 5 hours, 26 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Signature Silver with Atrium Health
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Elite Bronze
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Signature Expanded Bronze
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Signature Silver
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Signature Gold
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Signature Expanded Bronze with Atrium Health
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Signature Gold with Atrium Health
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Complete Gold + Vision + Adult Dental
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Everyday Bronze + Vision + Adult Dental
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Elite Bronze + Vision + Adult Dental
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Everyday Bronze with Atrium Health + Vision + Adult Dental
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Elite Bronze with Atrium Health + Vision + Adult Dental
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Focused Silver with Atrium Health + Vision + Adult Dental
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Complete Gold with Atrium Health + Vision + Adult Dental
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Signature Expanded Bronze + Vision + Adult Dental
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Signature Silver + Vision + Adult Dental
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Complete Gold
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Signature Gold + Vision + Adult Dental
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Signature Silver with Atrium Health + Vision + Adult Dental
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Signature Gold with Atrium Health + Vision + Adult Dental
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Enhanced Asthma/COPD Care Silver $0 Rx Options
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Everyday Bronze
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Streamlined Silver
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Streamlined Silver with Atrium Health
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Enhanced CHF Heart Care Silver $0 Rx Options
via dihydroergotamine mesylate 		Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 5 hours, 26 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via dihydroergotamine mesylate 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via dihydroergotamine mesylate 		Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Silver Premier + No Referrals
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ QL
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 5 hours, 26 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Focus 2026
via dihydroergotamine mesylate 		Tier 1 - Generic ✓ — — PA
BCBS Federal Standard Option 2026
via dihydroergotamine mesylate 		Tier 1 - Generic ✓ — — PA
BCBS Federal Basic Option 2026
via dihydroergotamine mesylate 		Tier 1 - Generic ✓ — — PA
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 5 hours, 26 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Value 2026
via dihydroergotamine mesylate 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Home with UNC Health Alliance 2026
via dihydroergotamine mesylate 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Advantage 2026
via dihydroergotamine mesylate 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Local 2026
via dihydroergotamine mesylate 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
BCBSNC Blue Care 2026
via dihydroergotamine mesylate 		Tier 2 - Medium Cost Generic/Brand — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 5 hours, 26 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
PruittHealth Premier (HMO I-SNP)
via dihydroergotamine mesylate 		Tier 1 - Preferred Generic ✓ — ✓ 16 per 30 days PA | QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via dihydroergotamine mesylate 		Tier 1 - Preferred Generic ✓ — ✓ 8 per 30 days PA | QL
Longevity Health Plan (HMO I-SNP)
via dihydroergotamine mesylate 		Tier 1 - Preferred Generic — — ✓ 8 per 28 days QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via dihydroergotamine mesylate 		Tier 1 - Preferred Generic ✓ — ✓ 16 per 30 days PA | QL
Provider Partners North Carolina Community Plan (HMO I-SNP)
via dihydroergotamine mesylate 		Tier 1 - Preferred Generic ✓ — ✓ 8 per 30 days PA | QL
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via dihydroergotamine mesylate 		Tier 1 - Preferred Generic ✓ — ✓ 8 per 30 days PA | QL
NHC Advantage (HMO I-SNP)
via dihydroergotamine mesylate 		Tier 1 - Preferred Generic ✓ — ✓ 16 per 30 days PA | QL
Liberty Medicare Dual Plan (HMO D-SNP)
via dihydroergotamine mesylate 		Tier 1 - Preferred Generic ✓ — ✓ 16 per 30 days PA | QL
Liberty Medicare Advantage (HMO C-SNP)
via dihydroergotamine mesylate 		Tier 2 - Generic ✓ — ✓ 16 per 30 days PA | QL
Senior Care (HMO I-SNP)
via dihydroergotamine mesylate 		Tier 2 - Generic ✓ — ✓ 16 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0017 (PPO)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
AARP Medicare Advantage from UHC NC-0019 (PPO)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred ✓ — ✓ 8 per 30 days PA | QL
UHC Complete Care NC-25 (HMO-POS C-SNP)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
Erickson Advantage Signature (HMO-POS)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
Erickson Advantage Guardian (HMO-POS I-SNP)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
Erickson Advantage Champion (HMO-POS C-SNP)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
Erickson Advantage Freedom (HMO-POS)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
Erickson Advantage Liberty (HMO-POS)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
UHC Complete Care NC-27 (HMO-POS C-SNP)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
UHC Complete Care NC-28 (HMO-POS C-SNP)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
UHC Dual Complete NC-S001 (PPO D-SNP)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
UHC Dual Complete NC-S2 (PPO D-SNP)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
HealthTeam Advantage Plan I (PPO)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred ✓ — ✓ 8 per 30 days PA | QL
HealthTeam Advantage Plan II (PPO)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred ✓ — ✓ 8 per 30 days PA | QL
HealthTeam Advantage Vitality Plan (PPO)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred ✓ — ✓ 8 per 30 days PA | QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
AARP Medicare Advantage from UHC NC-0001 (PPO)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
AARP Medicare Advantage from UHC NC-0004 (PPO)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
AARP Medicare Advantage from UHC NC-0016 (PPO)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ 16 per 28 days QL
Humana Dual Select H5525-072 (PPO D-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Humana Gold Plus H1036-137 (HMO-POS)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Humana Gold Plus H1036-233 (HMO-POS)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Humana Dual Select H1036-307 (HMO D-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Humana Gold Plus H1036-335 (HMO-POS)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Wellcare Simple Open (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty — — ✓ 8 per 28 days QL
Wellcare Dual Liberty Open (PPO D-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty — — ✓ 8 per 28 days QL
Wellcare Assist Open (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty — — ✓ 8 per 28 days QL
Wellcare Giveback Open (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty — — ✓ 8 per 28 days QL
Aetna Medicare Signature (HMO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Aetna Medicare Dual (HMO D-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Aetna Medicare Signature (HMO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Aetna Medicare Value Plus (HMO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Aetna Medicare Prime (HMO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Aetna Medicare Signature Care (HMO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Aetna Medicare Full Dual Care (HMO D-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Aetna Medicare Chronic Care (HMO C-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Aetna Medicare Enhanced (HMO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Aetna Medicare Chronic Care Value (HMO C-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Blue Medicare PPO Enhanced (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 28 days PA | QL
Blue Medicare Essential Plus (HMO-POS)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 28 days PA | QL
Blue Medicare Enhanced (HMO-POS)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 28 days PA | QL
Blue Medicare Choice (HMO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 28 days PA | QL
Blue Medicare Essential (HMO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 28 days PA | QL
Experience Health Medicare Advantage (HMO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 28 days PA | QL
Wellcare Simple (HMO-POS)
via dihydroergotamine mesylate 		Tier 5 - Specialty — — ✓ 8 per 28 days QL
Wellcare Dual Access (HMO-POS D-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty — — ✓ 8 per 28 days QL
Wellcare Dual Reserve (HMO-POS D-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty — — ✓ 8 per 28 days QL
Wellcare Dual Liberty (HMO-POS D-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty — — ✓ 8 per 28 days QL
Troy Medicare (HMO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
HumanaChoice Giveback H5216-017 (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
HumanaChoice H5216-211 (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Alignment Health Platinum (HMO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 28 days PA | QL
Alignment Health NC Duals (HMO-POS D-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 28 days PA | QL
Alignment Health smartHMO (HMO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 28 days PA | QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 28 days PA | QL
Alignment Health Platinum Select (HMO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 28 days PA | QL
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 28 days PA | QL
DEVOTED CORE 001 NC (HMO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
DEVOTED GIVEBACK 002 NC (HMO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
DEVOTED DUAL 009 NC (HMO D-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
DEVOTED GIVEBACK 012 NC (HMO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Aetna Medicare Enhanced (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Aetna Medicare Enhanced (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Aetna Medicare Signature Extra (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Aetna Medicare Signature Giveback (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Humana Full Access H5525-034 (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
HumanaChoice Giveback H5525-035 (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
HumanaChoice H5525-049 (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
HumanaChoice H5525-050 (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
HumanaChoice H5525-070 (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
HumanaChoice H5525-083 (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Humana Gold Plus H6622-025 (HMO-POS)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Humana Gold Plus H6622-026 (HMO-POS)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Humana Gold Plus H6622-057 (HMO-POS)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Humana Gold Plus H6622-060 (HMO-POS)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Humana Gold Plus H6622-061 (HMO-POS)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Alignment Health AVA (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 28 days PA | QL
HealthSpring True Choice (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty — — ✓ 8 per 28 days QL
Humana Gold Choice H8145-004 (PFFS)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
AmeriHealth Caritas VIP Care (HMO D-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
Healthy Blue + Medicare (HMO-POS D-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 28 days PA | QL
DEVOTED CHOICE 001 NC (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
DEVOTED CHOICE 003 NC (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
DEVOTED CHOICE 005 NC (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
DEVOTED CHOICE 008 NC (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via dihydroergotamine mesylate 		Tier 5 - Specialty ✓ — ✓ 8 per 30 days PA | QL
HealthSpring TotalCare (HMO D-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty — — ✓ 8 per 28 days QL
HealthSpring Preferred (HMO)
via dihydroergotamine mesylate 		Tier 5 - Specialty — — ✓ 8 per 28 days QL
HealthSpring TotalCare Plus (HMO D-SNP)
via dihydroergotamine mesylate 		Tier 5 - Specialty — — ✓ 8 per 28 days QL
HealthSpring Preferred Select (HMO)
via dihydroergotamine mesylate 		Tier 5 - Specialty — — ✓ 8 per 28 days QL
HealthSpring Preferred Savings (HMO)
via dihydroergotamine mesylate 		Tier 5 - Specialty — — ✓ 8 per 28 days QL
HealthSpring Preferred Plus (HMO)
via dihydroergotamine mesylate 		Tier 5 - Specialty — — ✓ 8 per 28 days QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 5 hours, 26 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026
via dihydroergotamine mesylate 		Not Covered — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via dihydroergotamine mesylate 		Not Covered — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via dihydroergotamine mesylate 		Not Covered — — — None
Source: Excel (XLSX)  ·  Formulary date: Sep 23, 2026  ·  Checked: 5 hours, 26 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026
via dihydroergotamine mesylate 		Tier 1 - Generic Formulary — — ✓ MIGRANAL NASAL SPRAY TO BE DISP AT MAX QTY OF 16 VIALS IN 22 DAYS OR 48 VIALS IN 68 DAYS QL Quantity limit
TRICARE Uniform Formulary 2026
via Brekiya 		Tier 3 - Non-Formulary ✓ — ✓ BREKIYA AUTO-INJECTOR (ML) TO BE DISPENSED AT MAXIMUM QUANTITY OF 12ML IN 23 DAYS OR 36ML IN 68 DAYS PA | QL PA: 1270/48001/90693 PA DRUGS, DOD PA REQUIRED; Quantity limit
TRICARE Uniform Formulary 2026 Tier 3 - Non-Formulary — — — None
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 5 hours, 26 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — — None
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — — None
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — — None
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — — None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — — None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — — None
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — — None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — — None
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — — None
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — — None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — — None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via dihydroergotamine mesylate 		Tier 4 - Non-Preferred — — ✓ QL
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