24HR Allergy Relief

Generic: levocetirizine dihydrochloride

5 MG — Tablet

ANTIHISTAMINE-1

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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Formulary date: Jan 1, 2026  ·  Checked: 4 hours, 31 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Signature Expanded Bronze
via Xyzal 		Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via Xyzal 		Tier 2 - Generic — — ✓ QL
Signature Gold + Vision + Adult Dental
via Xyzal 		Tier 2 - Generic — — ✓ QL
Signature Silver + Vision + Adult Dental
via Xyzal 		Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze + Vision + Adult Dental
via Xyzal 		Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental
via Xyzal 		Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental
via Xyzal 		Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via Xyzal 		Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Xyzal 		Tier 2 - Generic — — ✓ QL
Elite Bronze + Vision + Adult Dental
via Xyzal 		Tier 2 - Generic — — ✓ QL
Everyday Bronze + Vision + Adult Dental
via Xyzal 		Tier 2 - Generic — — ✓ QL
Complete Gold + Vision + Adult Dental
via Xyzal 		Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via Xyzal 		Tier 2 - Generic — — ✓ QL
Signature Gold with Atrium Health
via Xyzal 		Tier 2 - Generic — — ✓ QL
Signature Silver with Atrium Health
via Xyzal 		Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze with Atrium Health
via Xyzal 		Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health
via Xyzal 		Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health
via Xyzal 		Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health
via Xyzal 		Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health
via Xyzal 		Tier 2 - Generic — — ✓ QL
Signature Gold
via Xyzal 		Tier 2 - Generic — — ✓ QL
Signature Silver
via Xyzal 		Tier 2 - Generic — — ✓ QL
Signature Silver with Atrium Health + Vision + Adult Dental
via Xyzal 		Tier 2 - Generic — — ✓ QL
Clear Silver with $0 Insulin Options
via Xyzal 		Tier 2 - Generic — — ✓ QL
Elite Bronze
via Xyzal 		Tier 2 - Generic — — ✓ QL
Everyday Bronze
via Xyzal 		Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver $0 Rx Options
via Xyzal 		Tier 2 - Generic — — ✓ QL
Complete Gold
via Xyzal 		Tier 2 - Generic — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Streamlined Silver
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Streamlined Silver with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze + Vision + Adult Dental
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Signature Silver + Vision + Adult Dental
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Signature Gold + Vision + Adult Dental
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Signature Silver with Atrium Health + Vision + Adult Dental
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Signature Gold with Atrium Health + Vision + Adult Dental
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver $0 Rx Options
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Everyday Bronze
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Elite Bronze
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Clear Silver with $0 Insulin Options
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Complete Gold
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Signature Silver
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Signature Gold
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via Xyzal 		Tier 2 - Generic — — ✓ QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via Xyzal 		Tier 2 - Generic — — ✓ QL
Streamlined Silver
via Xyzal 		Tier 2 - Generic — — ✓ QL
Streamlined Silver with Atrium Health
via Xyzal 		Tier 2 - Generic — — ✓ QL
Enhanced CHF Heart Care Silver $0 Rx Options
via Xyzal 		Tier 2 - Generic — — ✓ QL
Signature Gold with Atrium Health + Vision + Adult Dental
via Xyzal 		Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Signature Expanded Bronze with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Signature Silver with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Signature Gold with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Complete Gold + Vision + Adult Dental
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Everyday Bronze + Vision + Adult Dental
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Elite Bronze + Vision + Adult Dental
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Complete Gold with Atrium Health + Vision + Adult Dental
via levocetirizine dihydrochloride 		Tier 2 - Generic — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 4 hours, 31 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 4 hours, 31 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Longevity Health Plan (HMO I-SNP)
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — — None
Wellcare Simple Open (PPO)
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Wellcare Dual Access (HMO-POS D-SNP)
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Wellcare Dual Reserve (HMO-POS D-SNP)
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Wellcare Dual Liberty (HMO-POS D-SNP)
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Troy Medicare (HMO)
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Wellcare Dual Liberty Open (PPO D-SNP)
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Wellcare Assist Open (PPO)
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Wellcare Giveback Open (PPO)
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Wellcare Simple (HMO-POS)
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — ✓ 300 per 30 days QL
Aetna Medicare Signature (HMO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Dual (HMO D-SNP)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Value Plus (HMO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Prime (HMO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Care (HMO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Full Dual Care (HMO D-SNP)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care (HMO C-SNP)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (HMO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Chronic Care Value (HMO C-SNP)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
DEVOTED CORE 001 NC (HMO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — ✓ 300 per 30 days QL
DEVOTED GIVEBACK 002 NC (HMO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — ✓ 300 per 30 days QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — ✓ 300 per 30 days QL
DEVOTED DUAL 009 NC (HMO D-SNP)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — ✓ 300 per 30 days QL
DEVOTED GIVEBACK 012 NC (HMO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — ✓ 300 per 30 days QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — ✓ 300 per 30 days QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — ✓ 300 per 30 days QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — ✓ 300 per 30 days QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — ✓ 300 per 30 days QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — ✓ 300 per 30 days QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — ✓ 300 per 30 days QL
Aetna Medicare Signature (PPO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Enhanced (PPO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Extra (PPO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature Giveback (PPO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
HealthSpring True Choice (PPO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
DEVOTED CHOICE 001 NC (PPO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — ✓ 300 per 30 days QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — ✓ 300 per 30 days QL
DEVOTED CHOICE 003 NC (PPO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — ✓ 300 per 30 days QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — ✓ 300 per 30 days QL
DEVOTED CHOICE 005 NC (PPO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — ✓ 300 per 30 days QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — ✓ 300 per 30 days QL
DEVOTED CHOICE 008 NC (PPO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — ✓ 300 per 30 days QL
HealthSpring TotalCare (HMO D-SNP)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred (HMO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Select (HMO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Savings (HMO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Plus (HMO)
via levocetirizine dihydrochloride 		Tier 4 - Non-Preferred — — — None
Source: CMS QHP JSON  ·  Formulary date: Oct 13, 2026  ·  Checked: 4 hours, 31 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
69803NC0010083
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Silver Simple PCP Saver | with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Silver Simple Diabetes | with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Silver Classic | with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Bronze Classic 4700 | with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Secure | with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Bronze Simple Chronic Care CKM | with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Gold Classic Standard | with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Silver Classic Standard | with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Bronze Classic Standard | with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Gold Classic Standard
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Silver Classic Standard
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Bronze Classic Standard
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Silver Simple Diabetes
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Silver Simple PCP Saver
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Bronze Classic 4700
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Secure
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Silver Classic
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
69803NC0010075
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
69803NC0010074
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Silver Simple Chronic Care CKM | with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Bronze Simple Diabetes | with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision | with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
69803NC0010076
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
69803NC0010077
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
69803NC0010078
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
69803NC0010079
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
69803NC0010080
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
69803NC0010081
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
69803NC0010082
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
69803NC0010084
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
69803NC0010085
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Bronze Simple Diabetes
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Silver Core Plan
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Silver Core Plan | with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Silver Simple Diabetes with Adult Dental & Vision
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
69803NC0010108
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
69803NC0010109
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
69803NC0010110
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
69803NC0010111
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
69803NC0010112
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
69803NC0010113
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
69803NC0010114
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
69803NC0010115
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
69803NC0010116
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
69803NC0010117
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Bronze Simple Diabetes with Adult Dental & Vision | with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Silver Simple Diabetes with Adult Dental & Vision | with Atrium Health
via levocetirizine dihydrochloride 		Tier 2 - Generic — — — None
Source: Excel (XLSX)  ·  Formulary date: Sep 23, 2026  ·  Checked: 4 hours, 31 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026 Tier 3 - Non-Formulary — — — None
TRICARE Uniform Formulary 2026
via Xyzal 		Tier 3 - Non-Formulary — — — None
TRICARE Uniform Formulary 2026
via levocetirizine dihydrochloride 		Tier 3 - Non-Formulary — — — None
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 4 hours, 31 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — — None
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals)
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — ✓ QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — ✓ QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — ✓ QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — ✓ QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals)
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — — None
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — ✓ QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals)
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — ✓ QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — ✓ QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — — None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — ✓ QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals)
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — ✓ QL
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals)
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — — None
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals)
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — — None
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals)
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — — None
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — — None
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals)
via levocetirizine dihydrochloride 		Tier 1 - Preferred Generic — — — None
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