Wide Seal Diaphragm

65MM, 70MM, 75MM, 80MM, 85 MM — DIAPHRAGM

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: 6 hours, 22 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 2 - Brand Formulary	—	—	✓ 1270/48001/87580 DOD SINGLE DOSE MEDS >30 DAYS: QUANTITY DQL	QL Quantity limit