Undecatrex

Generic: testosterone undecanoate

200 MG — Capsule

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

2 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 7 hours, 57 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Basic Option 2026 via Jatenzo	Tier 3 - Non-Preferred Brand	✓	—	—	PA
BCBS Federal Standard Option 2026 via Jatenzo	Tier 3 - Non-Preferred Brand	✓	—	—	PA

6 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 7 hours, 57 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - HDHP 2026 via Kyzatrex	Not Covered	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Tlando	Not Covered	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Tlando	Not Covered	—	—	—	None
NC State Health Plan - HDHP 2026 via Tlando	Not Covered	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Kyzatrex	Not Covered	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Kyzatrex	Not Covered	—	—	—	None

4 plans

Source: Excel (XLSX) · Formulary date: Sep 23, 2026 · Checked: 7 hours, 57 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026 via Tlando	Tier 3 - Non-Formulary	✓	—	—	PA PA: 1270/48001/90693 PA DRUGS, DOD PA REQUIRED
TRICARE Uniform Formulary 2026 via Kyzatrex	Tier 3 - Non-Formulary	✓	—	—	PA PA: 1270/48001/90693 PA DRUGS, DOD PA REQUIRED
TRICARE Uniform Formulary 2026 via Jatenzo	Tier 3 - Non-Formulary	✓	—	—	PA PA: 1270/48001/90693 PA DRUGS, DOD PA REQUIRED
TRICARE Uniform Formulary 2026	Tier 3 - Non-Formulary	✓	—	—	PA PA: 1270/48001/90693 PA DRUGS, DOD PA REQUIRED