No prior authorization
Does Ultimate Health Plans, INC. require prior authorization for PEDIARIX?
Ultimate Health Plans, INC. does not require prior authorization for PEDIARIX on the Medicare Part D plans that cover it.
No covering plan from this payer files a prior-authorization requirement for this drug.
By product strength
| RxNorm product | Plans covering | Require prior auth | Step therapy | Qty limit | Status |
|---|---|---|---|---|---|
| 0.5 ML acellular pertussis vaccine, inactivated 0.116 MG/ML / diphtheria toxoid vaccine, inactivated 50 UNT/ML / hepatitis B surface antigen vaccine 0.02 MG/ML / poliovirus vaccine inactivated, type 1 (Mahoney) 80 UNT/ML / poliovirus vaccine inactivated, type 2 (MEF-1) 16 UNT/ML / poliovirus vaccine inactivated, type 3 (Saukett) 64 UNT/ML / tetanus toxoid vaccine, inactivated 20 UNT/ML Prefilled Syringe [PEDIARIX]829989 | 16 / 16 | 0 | 0 | 0 | No prior authorization |
Product names come from RxNorm (U.S. National Library of Medicine).
Plan-by-plan detail — 0.5 ML acellular pertussis vaccine, inactivated 0.116 MG/ML / diphtheria toxoid vaccine, inactivated 50 UNT/ML / hepatitis B surface antigen vaccine 0.02 MG/ML / poliovirus vaccine inactivated, type 1 (Mahoney) 80 UNT/ML / poliovirus vaccine inactivated, type 2 (MEF-1) 16 UNT/ML / poliovirus vaccine inactivated, type 3 (Saukett) 64 UNT/ML / tetanus toxoid vaccine, inactivated 20 UNT/ML Prefilled Syringe [PEDIARIX]
| Plan | Contract | Tier | Prior auth | Step therapy | Qty limit |
|---|---|---|---|---|---|
| Advantage Care by Ultimate (HMO C-SNP) | H2962-021 | 3 | No | No | No |
| Advantage Care by Ultimate (HMO C-SNP) | H2962-026 | 3 | No | No | No |
| Advantage Care by Ultimate (HMO C-SNP) | H2962-029 | 3 | No | No | No |
| Advantage Care by Ultimate (HMO C-SNP) | H2962-033 | 3 | No | No | No |
| Advantage Care by Ultimate (HMO C-SNP) | H2962-050 | 3 | No | No | No |
| Advantage Care by Ultimate (HMO C-SNP) | H2962-051 | 3 | No | No | No |
| Advantage Care by Ultimate (HMO C-SNP) | H2962-052 | 3 | No | No | No |
| Advantage Care COPD by Ultimate (HMO C-SNP) | H2962-023 | 3 | No | No | No |
| Advantage Care COPD by Ultimate (HMO C-SNP) | H2962-025 | 3 | No | No | No |
| Advantage Plus by Ultimate (Full) (HMO D-SNP) | H2962-035 | 3 | No | No | No |
| Advantage Plus by Ultimate (Partial) (HMO D-SNP) | H2962-036 | 3 | No | No | No |
| Premier by Ultimate (HMO) | H2962-001 | 3 | No | No | No |
| Premier by Ultimate (HMO) | H2962-028 | 3 | No | No | No |
| Premier by Ultimate (HMO) | H2962-045 | 3 | No | No | No |
| Premier by Ultimate (HMO) | H2962-046 | 3 | No | No | No |
| Premier by Ultimate (HMO) | H2962-047 | 3 | No | No | No |
Source
Monthly Prescription Drug Plan Formulary and Pharmacy Network Information — Basic Drugs Formulary File- Effective
- 2026-06-30
- Retrieved
- 2026-07-19
- SHA-256
- e626e6bcda1aa6a0071e6f0df6bafe686ae41842cdf0a9feffdc649b6d3ff3ae
We publish the hash of the exact file we ingested so any answer can be audited against the bytes CMS served that day.
PEDIARIX at other payers
Administrative information only. Benefily reports what a payer has published in its own prior-authorization policy as of the effective date shown. It is not medical advice, not a coverage or payment guarantee, and not an authorization. Requirements vary by plan, place of service and member benefits — always verify with the payer before rendering service.