Vistogard

Generic: uridine triacetate

10000 MG

Also known as: uridine triacetate
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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: 7 hours, 5 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Signature Silver with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — — PA
Signature Gold with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — — PA
Signature Silver + Vision + Adult Dental Tier 5 - Specialty ✓ — — PA
Clear Silver with $0 Insulin Options Tier 5 - Specialty ✓ — — PA
Signature Expanded Bronze Tier 5 - Specialty ✓ — — PA
Signature Silver Tier 5 - Specialty ✓ — — PA
Complete Gold Tier 5 - Specialty ✓ — — PA
Signature Gold Tier 5 - Specialty ✓ — — PA
Enhanced Asthma/COPD Care Silver $0 Rx Options Tier 5 - Specialty ✓ — — PA
Everyday Bronze Tier 5 - Specialty ✓ — — PA
Elite Bronze Tier 5 - Specialty ✓ — — PA
Everyday Bronze with Atrium Health Tier 5 - Specialty ✓ — — PA
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental Tier 5 - Specialty ✓ — — PA
Clear Silver with $0 Insulin Options + Vision + Adult Dental Tier 5 - Specialty ✓ — — PA
Elite Bronze with Atrium Health Tier 5 - Specialty ✓ — — PA
Streamlined Silver Tier 5 - Specialty ✓ — — PA
Streamlined Silver with Atrium Health Tier 5 - Specialty ✓ — — PA
Enhanced CHF Heart Care Silver $0 Rx Options Tier 5 - Specialty ✓ — — PA
Focused Silver with Atrium Health Tier 5 - Specialty ✓ — — PA
Complete Gold with Atrium Health Tier 5 - Specialty ✓ — — PA
Signature Expanded Bronze with Atrium Health Tier 5 - Specialty ✓ — — PA
Signature Silver with Atrium Health Tier 5 - Specialty ✓ — — PA
Signature Gold with Atrium Health Tier 5 - Specialty ✓ — — PA
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental Tier 5 - Specialty ✓ — — PA
Complete Gold + Vision + Adult Dental Tier 5 - Specialty ✓ — — PA
Everyday Bronze + Vision + Adult Dental Tier 5 - Specialty ✓ — — PA
Elite Bronze + Vision + Adult Dental Tier 5 - Specialty ✓ — — PA
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — — PA
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — — PA
Focused Silver with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — — PA
Complete Gold with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — — PA
Signature Expanded Bronze + Vision + Adult Dental Tier 5 - Specialty ✓ — — PA
Signature Gold + Vision + Adult Dental Tier 5 - Specialty ✓ — — PA
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 5 - Specialty ✓ — — PA
Source: PDF  ·  Formulary date: Oct 7, 2026  ·  Checked: 7 hours, 5 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Gold 1500 Indiv Med Deductible Tier 5 - Specialty — — — None
Connect Silver 3600 Indiv Med Deductible Tier 5 - Specialty — — — None
Connect Bronze CMS Standard Tier 5 - Specialty — — — None
Connect myDiabetesCare Bronze Tier 5 - Specialty — — — None
Connect Silver 5000 Indiv Med Deductible Tier 5 - Specialty — — — None
Connect Silver 3000 Indiv Med Deductible Tier 5 - Specialty — — — None
Connect Silver CMS Standard Tier 5 - Specialty — — — None
Connect Bronze RD 6000 Indiv Med Deductible Tier 5 - Specialty — — — None
Connect Bronze RD CMS Standard Tier 5 - Specialty — — — None
Connect Silver RD 3500 Indiv Med Deductible Tier 5 - Specialty — — — None
Connect Silver RD 5000 Indiv Med Deductible Tier 5 - Specialty — — — None
Connect Silver RD CMS Standard Tier 5 - Specialty — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 5 - Specialty — — — None
Connect Gold RD CMS Standard Tier 5 - Specialty — — — None
Connect Bronze 7000 HSA Indiv Med Deductible Tier 5 - Specialty — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 5 - Specialty — — — None
Connect Gold CMS Standard Tier 5 - Specialty — — — None
Connect myDiabetesCare Silver Tier 5 - Specialty — — — None
Connect Bronze RD 5000 Indiv Med Deductible Tier 5 - Specialty — — — None
Connect Bronze 6500 Indiv Med Deductible Tier 5 - Specialty — — — None
Source: CMS QHP JSON  ·  Checked: 7 hours, 5 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Bronze Classic Standard Tier 3 - Preferred Brand — — ✓ QL
Silver Classic Standard Tier 3 - Preferred Brand — — ✓ QL
Gold Classic Standard Tier 3 - Preferred Brand — — ✓ QL
Bronze Classic Standard | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Classic Standard | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Gold Classic Standard | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Bronze Simple Chronic Care CKM | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Secure | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Classic Tier 3 - Preferred Brand — — ✓ QL
Bronze Elite + PCP Saver Plus Tier 3 - Preferred Brand — — ✓ QL
Bronze Classic 4700 | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Classic | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Diabetes | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Simple PCP Saver | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Gold Elite Saver Plus | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Bronze Simple Diabetes | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Chronic Care CKM | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
AIAN Cost Share Tier 3 - Preferred Brand — — ✓ QL
AIAN Cost Share | with Atrium Health Tier 3 - Preferred Brand — — ✓ QL
Silver Simple PCP Saver Tier 3 - Preferred Brand — — ✓ QL
Bronze Classic 4700 Tier 3 - Preferred Brand — — ✓ QL
Secure Tier 3 - Preferred Brand — — ✓ QL
Gold Elite Saver Plus Tier 3 - Preferred Brand — — ✓ QL
Silver Simple Diabetes Tier 3 - Preferred Brand — — ✓ QL
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