bismuth subcitrate 140 MG / metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule [Pylera]
bismuth subcitrate
RxCUI: 1294621
What the CMS Formulary Data Shows for bismuth subcitrate 140 MG / metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule [Pylera]
Per the CMS 2026 Part D formulary file, bismuth subcitrate 140 MG / metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule [Pylera] (RxNorm concept RXCUI 1294621, generic name bismuth subcitrate) appears on 5 distinct formulary files spanning 32 Medicare Part D plan offerings - 0.6% of enrollable Part D products, selective placement; verify formulary inclusion before enrolling. Tier placement ranges from Tier 1 to Tier 4, with a cross-plan average of Tier 3.4.
Real-world access to bismuth subcitrate 140 MG / metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule [Pylera] depends on utilization management as much as tier placement: 20% of covering formularies require prior authorization. 0% require step therapy. 20% apply quantity limits.
Medicare Part D spending dashboard figures are not published for this drug. The plan-by-plan detail below lists exactly which PDP and MA-PD contracts carry bismuth subcitrate 140 MG / metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule [Pylera] today.
Coverage Details
- Formularies covering
- 5
- Plans covering
- 32
- Coverage rate
- 0.6%
- Tier range
- Tier 1 – Tier 4
- Average tier
- Tier 3, Preferred Brand
Restrictions
- Prior authorization required
- 20% of formularies
- Step therapy required
- 0% of formularies
- Quantity limits
- 20% of formularies
Tier Distribution Across Plans
Medicare Advantage Plans (MA-PD) Covering bismuth subcitrate 140 MG / metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule [Pylera]
32 Medicare Advantage plans with Part D drug coverage include this drug.
| Plan | Insurer | Tier | PA | Premium | States |
|---|---|---|---|---|---|
| Hamaspik Medicare Choice (HMO D-SNP) | HAMASPIK, INC. | T1 | No | $0 | NY |
| Hamaspik Medicare Select (HMO D-SNP) | HAMASPIK, INC. | T1 | No | $34.50 | NY |
| Medicare BlueEssential (PPO) | EXCELLUS HEALTH PLAN, INC. | T4 | No | $0 | NY |
| Medicare BlueActive (PPO) | EXCELLUS HEALTH PLAN, INC. | T4 | No | $0 | NY |
| Medicare BlueVital (PPO) | EXCELLUS HEALTH PLAN, INC. | T4 | No | $0 | NY |
| Univera SeniorChoice Basic (HMO) | EXCELLUS HEALTH PLAN, INC. | T4 | No | $0 | NY |
| Univera SeniorChoice Extra (HMO) | EXCELLUS HEALTH PLAN, INC. | T4 | No | $0 | NY |
| Medicare Blue Choice Core (HMO) | EXCELLUS HEALTH PLAN, INC. | T4 | No | $0 | NY |
| Univera Medicare Dual (HMO D-SNP) | EXCELLUS HEALTH PLAN COMMUNITY CARE LLC | T4 | No | $0 | NY |
| Medicare Blue Dual (HMO D-SNP) | EXCELLUS HEALTH PLAN COMMUNITY CARE LLC | T4 | No | $0 | NY |
| DrMax (HMO) | DOCTORS HEALTHCARE PLANS, INC. | T4 | Yes | $0 | FL |
| DrExtraCare (HMO C-SNP) | DOCTORS HEALTHCARE PLANS, INC. | T4 | Yes | $0 | FL |
| DrSelect (HMO) | DOCTORS HEALTHCARE PLANS, INC. | T4 | Yes | $0 | FL |
| DrSelect-CFL (HMO) | DOCTORS HEALTHCARE PLANS, INC. | T4 | Yes | $0 | FL |
| DrPlatinum-CFL (HMO D-SNP) | DOCTORS HEALTHCARE PLANS, INC. | T4 | Yes | $0 | FL |
| DrTotalCare-CFL (HMO C-SNP) | DOCTORS HEALTHCARE PLANS, INC. | T4 | Yes | $0 | FL |
| DrElite-SFL (HMO) | DOCTORS HEALTHCARE PLANS, INC. | T4 | Yes | $0 | FL |
| CDPHP $0 Medicare Rx (HMO) | CAPITAL DISTRICT PHYSICIANS' HEALTH PLAN, INC. | T4 | No | $0 | NY |
| DrFlex (HMO D-SNP) | DOCTORS HEALTHCARE PLANS, INC. | T4 | Yes | $1.10 | FL |
| DrPlus (HMO D-SNP) | DOCTORS HEALTHCARE PLANS, INC. | T4 | Yes | $4.80 | FL |
| Univera SeniorChoice Core (PPO) | EXCELLUS HEALTH PLAN, INC. | T4 | No | $33.00 | NY |
| Univera SeniorChoice Advanced (HMO-POS) | EXCELLUS HEALTH PLAN, INC. | T4 | No | $36.90 | NY |
| Medicare BlueClassic (PPO) | EXCELLUS HEALTH PLAN, INC. | T4 | No | $51.00 | NY |
| Univera SeniorChoice Secure (HMO-POS) | EXCELLUS HEALTH PLAN, INC. | T4 | No | $54.90 | NY |
| Medicare BlueBalanced (PPO) | EXCELLUS HEALTH PLAN, INC. | T4 | No | $55.00 | NY |
| Medicare Blue Choice Prime (HMO) | EXCELLUS HEALTH PLAN, INC. | T4 | No | $55.00 | NY |
| Univera SeniorChoice Value Plus (HMO-POS) | EXCELLUS HEALTH PLAN, INC. | T4 | No | $58.60 | NY |
| Medicare BlueEnhanced (PPO) | EXCELLUS HEALTH PLAN, INC. | T4 | No | $70.30 | NY |
| Medicare BluePlus (PPO) | EXCELLUS HEALTH PLAN, INC. | T4 | No | $86.40 | NY |
| CDPHP Clear Rx (HMO) | CAPITAL DISTRICT PHYSICIANS' HEALTH PLAN, INC. | T4 | No | $100.00 | NY |
| CDPHP Choice Rx (HMO) | CAPITAL DISTRICT PHYSICIANS' HEALTH PLAN, INC. | T4 | No | $135.00 | NY |
| Medicare Blue Choice Optimum (HMO-POS) | EXCELLUS HEALTH PLAN, INC. | T4 | No | $146.00 | NY |
Frequently Asked Questions
Is bismuth subcitrate 140 MG / metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule [Pylera] covered by Medicare Part D?
Yes, bismuth subcitrate 140 MG / metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule [Pylera] is covered by 32 Medicare Part D plans (0.6% of all Part D formularies).
What tier is bismuth subcitrate 140 MG / metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule [Pylera] on Medicare Part D plans?
bismuth subcitrate 140 MG / metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule [Pylera] averages Tier 3.4 across Part D plans, ranging from Tier 1 to Tier 4.
Does bismuth subcitrate 140 MG / metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule [Pylera] require prior authorization?
20% of Part D formularies require prior authorization for bismuth subcitrate 140 MG / metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule [Pylera]. Step therapy: 0%. Quantity limits: 20%.
Read our methodology - how this data is sourced, computed, and verified.