bismuth subcitrate 140 MG / metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule
bismuth subcitrate
RxCUI: 1294619
What the CMS Formulary Data Shows for bismuth subcitrate 140 MG / metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule
Per the CMS 2026 Part D formulary file, bismuth subcitrate 140 MG / metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule (RxNorm concept RXCUI 1294619, generic name bismuth subcitrate) appears on 13 distinct formulary files spanning 220 Medicare Part D plan offerings - 4.3% 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 3.2.
Real-world access to bismuth subcitrate 140 MG / metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule depends on utilization management as much as tier placement: 0% of covering formularies require prior authorization. 0% require step therapy. 15.4% 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 today.
Coverage Details
- Formularies covering
- 13
- Plans covering
- 220
- Coverage rate
- 4.3%
- Tier range
- Tier 1 – Tier 4
- Average tier
- Tier 3, Preferred Brand
Restrictions
- Prior authorization required
- 0% of formularies
- Step therapy required
- 0% of formularies
- Quantity limits
- 15.4% 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
100 Medicare Advantage plans with Part D drug coverage include this drug.
| Plan | Insurer | Tier | PA | Premium | States |
|---|---|---|---|---|---|
| CareAdvantage (HMO D-SNP) | SAN MATEO HEALTH COMMISSION | T1 | No | $0 | CA |
| Hamaspik Medicare Choice (HMO D-SNP) | HAMASPIK, INC. | T1 | No | $0 | NY |
| Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | No | $0 | PA |
| Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | No | $0 | PA |
| Highmark Health Options Duals (HMO D-SNP) | HIGHMARK HEALTH OPTIONS WEST VIRGINIA INC. | T1 | No | $0 | WV |
| Highmark Health Options Duals (HMO D-SNP) | HIGHMARK BCBSD, INC. | T1 | No | $0 | DE |
| Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | No | $13.10 | PA |
| Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | No | $17.60 | PA |
| Highmark Health Options Duals Select (HMO D-SNP) | HIGHMARK BCBSD, INC. | T1 | No | $31.20 | DE |
| Hamaspik Medicare Select (HMO D-SNP) | HAMASPIK, INC. | T1 | No | $34.50 | NY |
| MCS Classicare RxMax (HMO) | MCS ADVANTAGE, INC. | T2 | No | $0 | PR |
| 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 |
| Alignment Health the ONE + Walgreens (HMO) | ALIGNMENT HEALTH PLAN OF ARIZONA, INC. | T4 | No | $0 | AZ |
| Alignment Health the ONE + Walgreens (HMO) | ALIGNMENT HEALTH PLAN OF ARIZONA, INC. | T4 | No | $0 | AZ |
| Alignment Health Heart & Diabetes (HMO C-SNP) | ALIGNMENT HEALTH PLAN OF ARIZONA, INC. | T4 | No | $0 | AZ |
| Alignment Health smartHMO (HMO) | ALIGNMENT HEALTH PLAN OF ARIZONA, INC. | T4 | No | $0 | AZ |
| Alignment Health My Choice (HMO) | ALIGNMENT HEALTH PLAN | T4 | No | $0 | CA |
| Alignment Health Platinum + Instacart (HMO) | ALIGNMENT HEALTH PLAN | T4 | No | $0 | CA |
| Alignment Health Heart & Diabetes (HMO C-SNP) | ALIGNMENT HEALTH PLAN | T4 | No | $0 | CA |
| Alignment Health AllCare Preferred (HMO) | ALIGNMENT HEALTH PLAN | T4 | No | $0 | CA |
| Alignment Health smartHMO (HMO) | ALIGNMENT HEALTH PLAN | T4 | No | $0 | CA |
| Alignment Health Platinum + Instacart (HMO-POS) | ALIGNMENT HEALTH PLAN | T4 | No | $0 | CA |
| Alignment Health My Choice (HMO) | ALIGNMENT HEALTH PLAN | T4 | No | $0 | CA |
| Alignment Health Harmony (HMO) | ALIGNMENT HEALTH PLAN | T4 | No | $0 | CA |
| Alignment Health Balance (HMO C-SNP) | ALIGNMENT HEALTH PLAN | T4 | No | $0 | CA |
| Alignment Health the ONE (HMO) | ALIGNMENT HEALTH PLAN | T4 | No | $0 | CA |
| Alignment Health the ONE + Walgreens (HMO) | ALIGNMENT HEALTH PLAN | T4 | No | $0 | CA |
| Alignment Health smartHMO (HMO) | ALIGNMENT HEALTH PLAN | T4 | No | $0 | CA |
| Alignment Health smartHMO (HMO) | ALIGNMENT HEALTH PLAN | T4 | No | $0 | CA |
| Alignment Health CommUnity (HMO) | ALIGNMENT HEALTH PLAN | T4 | No | $0 | CA |
| Alignment Health smartSavings (HMO) | ALIGNMENT HEALTH PLAN | T4 | No | $0 | CA |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | ALIGNMENT HEALTH PLAN | T4 | No | $0 | CA |
| Alignment Health My Choice Select (HMO) | ALIGNMENT HEALTH PLAN | T4 | No | $0 | CA |
| Alignment Health My Choice CalCare (HMO) | ALIGNMENT HEALTH PLAN | T4 | No | $0 | CA |
| Alignment Health Honor+ Plan (HMO) | ALIGNMENT HEALTH PLAN | T4 | No | $0 | CA |
| Alignment Health ValorCare (HMO) | ALIGNMENT HEALTH PLAN | T4 | No | $0 | CA |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | ALIGNMENT HEALTH PLAN | T4 | No | $0 | CA |
| Alignment Health L.A. Premium Giveback (HMO) | ALIGNMENT HEALTH PLAN | T4 | No | $0 | CA |
| Alignment Health S.D. Premium Giveback (HMO) | ALIGNMENT HEALTH PLAN | T4 | No | $0 | CA |
| Alignment Health Platinum (HMO) | ALIGNMENT HEALTH PLAN OF NORTH CAROLINA, INC. | T4 | No | $0 | NC |
| Alignment Health NC Duals (HMO-POS D-SNP) | ALIGNMENT HEALTH PLAN OF NORTH CAROLINA, INC. | T4 | No | $0 | NC |
| Alignment Health smartHMO (HMO) | ALIGNMENT HEALTH PLAN OF NORTH CAROLINA, INC. | T4 | No | $0 | NC |
| Alignment Health Platinum + Instacart (HMO) | ALIGNMENT HEALTH PLAN OF NORTH CAROLINA, INC. | T4 | No | $0 | NV |
Frequently Asked Questions
Is bismuth subcitrate 140 MG / metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule covered by Medicare Part D?
Yes, bismuth subcitrate 140 MG / metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule is covered by 220 Medicare Part D plans (4.3% of all Part D formularies).
What tier is bismuth subcitrate 140 MG / metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule on Medicare Part D plans?
bismuth subcitrate 140 MG / metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule averages Tier 3.2 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 require prior authorization?
0% of Part D formularies require prior authorization for bismuth subcitrate 140 MG / metronidazole 125 MG / tetracycline hydrochloride 125 MG Oral Capsule. Step therapy: 0%. Quantity limits: 15.4%.
Read our methodology - how this data is sourced, computed, and verified.