Xywav

Generic: calcium oxybate

234 MG — Solution

Also known as: XYWAV SOL 0.5GM/ML calcium oxybate

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

2 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 1 hour, 24 minutes ago

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

3 plans

Source: CMS QHP JSON · Formulary date: Mar 18, 2026 · Checked: 1 hour, 24 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
AmeriHealth Caritas VIP Care (HMO D-SNP)	Tier 5 - Specialty	✓	—	—	PA
Troy Medicare (HMO)	Tier 5 - Specialty	✓	—	—	PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)	Tier 5 - Specialty	✓	—	—	PA

3 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 1 hour, 24 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - 80/20 Plus PPO 2026	Tier 5 - Preferred Brand Specialty	✓	—	✓	PA \| QL
NC State Health Plan - 70/30 Standard PPO 2026	Tier 5 - Preferred Brand Specialty	✓	—	✓	PA \| QL
NC State Health Plan - HDHP 2026	Tier 5 - Preferred Brand Specialty	✓	—	✓	PA \| QL