Vyleesi

1.749 MG — AUTO-INJECTOR (ML)

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: 5 hours, 26 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 2 - Brand Formulary	✓	—	✓ SUBCUTANEOUS VYLEESI TO BE DISP AT A MAX QUANTITY OF 2.4ML IN 23 DAYS AT RETAIL AND MAIL	PA \| QL PA: 1270/48001/90693 PA DRUGS, DOD PA REQUIRED; Quantity limit