Voquezna Triple Pak

Generic: vonoprazan/amoxicillin/clarith

20-500-500 — Pack

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: Sep 23, 2026 · Checked: 8 hours, 55 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 3 - Non-Formulary	✓	—	✓ VOQUEZNA TRIPLE PAK TO BE DISP AT A MAXIMUM QUANTITY OF 112 UNITS IN 14 DAYS	PA \| QL PA: 1270/48001/90693 PA DRUGS, DOD PA REQUIRED; Quantity limit