bupropion hcl
100 mg, 150 mg, 300 mg, 450 mg, 75 mg — Tablet
Also known as:
bupropion hcl oral
bupropion hcl tabs 75mg, 100mg; tb12 100mg, 150mg, 200mg; tb24 150mg, 300mg
bupropion hcl tab er 12hr 100 mg, 150 mg, 200 mg
bupropion hcl tab er 24hr 150 mg, 300 mg
bupropion hcl tab 75 mg, 100 mg
bupropion hcl tabs 75mg, 100mg; tb12 100mg, 150mg, 200mg; tb24 150mg, 300mg, 450mg
BUPROPION XL
WELLBUTRIN SR
WELLBUTRIN XL
FORFIVO XL
BUPROPION HCL SR
bupropion hcl tabs 75mg, 100mg; tb12 100mg,
buPROPion HCl Oral Tablet
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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.
AmeriHealth Caritas NC
10 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Gold Premier + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Premier + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Signature + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Gold Signature + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Essential + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Essential + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Signature + No Referrals | Tier 2 - Generic | — | — | — | None |
Blue Cross Blue Shield Federal
6 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBS Federal Focus 2026 | Tier 1 - Generic | — | — | — | None |
| BCBS Federal Basic Option 2026 | Tier 1 - Generic | — | — | — | None |
| BCBS Federal Standard Option 2026 | Tier 1 - Generic | — | — | — | None |
|
BCBS Federal Basic Option 2026
via Wellbutrin SR |
Tier 3 - Non-Preferred Brand | — | — | — | None |
|
BCBS Federal Standard Option 2026
via Wellbutrin SR |
Tier 3 - Non-Preferred Brand | — | — | — | None |
|
BCBS Federal Standard Option 2026
via Wellbutrin Xl |
Tier 3 - Non-Preferred Brand | — | — | — | None |
Blue Cross Blue Shield of NC
15 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
BCBSNC Blue Care 2026
via Wellbutrin SR |
Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
| BCBSNC Blue Value 2026 | Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
| BCBSNC Blue Care 2026 | Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
| BCBSNC Blue Local 2026 | Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
| BCBSNC Blue Home with UNC Health Alliance 2026 | Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
| BCBSNC Blue Advantage 2026 | Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
|
BCBSNC Blue Value 2026
via Wellbutrin Xl |
Tier 1 - Lowest Cost Generic | — | — | — | None |
|
BCBSNC Blue Care 2026
via Wellbutrin Xl |
Tier 1 - Lowest Cost Generic | — | — | — | None |
|
BCBSNC Blue Local 2026
via Wellbutrin Xl |
Tier 1 - Lowest Cost Generic | — | — | — | None |
|
BCBSNC Blue Home with UNC Health Alliance 2026
via Wellbutrin Xl |
Tier 1 - Lowest Cost Generic | — | — | — | None |
|
BCBSNC Blue Advantage 2026
via Wellbutrin Xl |
Tier 1 - Lowest Cost Generic | — | — | — | None |
|
BCBSNC Blue Value 2026
via Wellbutrin SR |
Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
|
BCBSNC Blue Local 2026
via Wellbutrin SR |
Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
|
BCBSNC Blue Home with UNC Health Alliance 2026
via Wellbutrin SR |
Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
|
BCBSNC Blue Advantage 2026
via Wellbutrin SR |
Tier 1 - Lowest Cost Generic | — | — | ✓ | QL |
Cigna
40 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Connect Bronze CMS Standard | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Gold RD CMS Standard | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Bronze RD CMS Standard | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Gold CMS Standard | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Silver RD CMS Standard | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Silver CMS Standard | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Bronze 6500 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Silver 3000 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Silver RD 5000 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Silver 4400 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Bronze 7000 HSA Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Silver RD 3500 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Bronze RD 5000 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Silver 3500 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Bronze RD 6000 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Bronze 5500 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect myDiabetesCare Bronze | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Gold 1500 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect Silver RD 2200 Indiv Med Deductible | Tier 2 - Generic | — | — | ✓ | QL |
| Connect myDiabetesCare Silver | Tier 2 - Generic | — | — | ✓ | QL |
|
Connect Bronze RD CMS Standard
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
Connect Gold RD CMS Standard
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
Connect Bronze CMS Standard
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
Connect Silver RD CMS Standard
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
Connect Gold CMS Standard
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
Connect Silver CMS Standard
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
Connect Bronze 6500 Indiv Med Deductible
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
Connect Silver 3000 Indiv Med Deductible
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
Connect Silver RD 5000 Indiv Med Deductible
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
Connect Silver 4400 Indiv Med Deductible
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
Connect Bronze 7000 HSA Indiv Med Deductible
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
Connect Silver RD 3500 Indiv Med Deductible
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
Connect Bronze RD 5000 Indiv Med Deductible
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
Connect Silver 3500 Indiv Med Deductible
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
Connect Bronze RD 6000 Indiv Med Deductible
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
Connect Bronze 5500 Indiv Med Deductible
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
Connect myDiabetesCare Bronze
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
Connect Gold 1500 Indiv Med Deductible
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
Connect Silver RD 2200 Indiv Med Deductible
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
Connect myDiabetesCare Silver
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
Medicare Part D
280 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
|
Longevity Health Plan (HMO I-SNP)
via BUPROPION HCL SR |
Tier 1 - Preferred Generic | — | — | ✓ 60 per 30 days | QL |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
|
NHC Advantage (HMO I-SNP)
via BUPROPION HCL SR |
Tier 1 - Preferred Generic | — | — | — | None |
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
|
PruittHealth Premier (HMO I-SNP)
via BUPROPION HCL SR |
Tier 1 - Preferred Generic | — | — | — | None |
| PruittHealth Premier (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
|
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via BUPROPION HCL SR |
Tier 1 - Preferred Generic | — | — | — | None |
|
Liberty Medicare Dual Plan (HMO D-SNP)
via BUPROPION HCL SR |
Tier 1 - Preferred Generic | — | — | — | None |
| Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Liberty Medicare Dual Plan (HMO D-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
|
Liberty Medicare Advantage (HMO C-SNP)
via BUPROPION HCL SR |
Tier 1 - Preferred Generic | — | — | — | None |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
|
Troy Medicare (HMO)
via BUPROPION HCL SR |
Tier 1 - Preferred Generic | — | — | — | None |
|
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via BUPROPION HCL SR |
Tier 1 - Preferred Generic | — | — | — | None |
| Troy Medicare (HMO) | Tier 1 - Preferred Generic | — | — | — | None |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
|
AmeriHealth Caritas VIP Care (HMO D-SNP)
via BUPROPION HCL SR |
Tier 1 - Preferred Generic | — | — | ✓ 60 per 30 days | QL |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
|
Provider Partners North Carolina Advantage Plan (HMO I-SNP)
via BUPROPION HCL SR |
Tier 1 - Preferred Generic | — | — | ✓ 60 per 30 days | QL |
|
Provider Partners North Carolina Community Plan (HMO I-SNP)
via BUPROPION HCL SR |
Tier 1 - Preferred Generic | — | — | ✓ 60 per 30 days | QL |
|
Provider Partners North Carolina Essential Plan (HMO I-SNP)
via BUPROPION HCL SR |
Tier 1 - Preferred Generic | — | — | ✓ 60 per 30 days | QL |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
|
Senior Care (HMO I-SNP)
via BUPROPION HCL SR |
Tier 1 - Preferred Generic | — | — | — | None |
| Senior Care (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
|
Aetna Medicare Signature Care (HMO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Aetna Medicare Prime (HMO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Aetna Medicare Chronic Care (HMO C-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Aetna Medicare Chronic Care Value (HMO C-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Aetna Medicare Chronic Care (HMO C-SNP) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
|
Erickson Advantage Signature (HMO-POS)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
HealthSpring True Choice (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| HealthSpring True Choice (PPO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
|
Aetna Medicare Value Plus (HMO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Aetna Medicare Signature (HMO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
HealthSpring TotalCare (HMO D-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
HealthSpring TotalCare Plus (HMO D-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| HealthSpring TotalCare (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
|
HealthSpring Preferred (HMO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
HealthSpring Preferred Select (HMO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
HealthSpring Preferred Savings (HMO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
HealthSpring Preferred Plus (HMO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Aetna Medicare Dual (HMO D-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| HealthSpring Preferred (HMO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| HealthSpring Preferred Select (HMO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| HealthSpring Preferred Savings (HMO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| HealthSpring Preferred Plus (HMO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
|
DEVOTED DUAL FULL 013 NC (HMO D-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| DEVOTED DUAL FULL 013 NC (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
|
Aetna Medicare Signature (HMO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Erickson Advantage Champion (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
| UHC Complete Care NC-28 (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
| UHC Complete Care NC-27 (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
|
Erickson Advantage Champion (HMO-POS C-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
UHC Complete Care NC-28 (HMO-POS C-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
UHC Complete Care NC-27 (HMO-POS C-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
UHC Complete Care NC-25 (HMO-POS C-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Liberty (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Freedom (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 2 - Generic | — | — | — | None |
| Erickson Advantage Signature (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
|
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
DEVOTED DUAL 009 NC (HMO D-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| DEVOTED DUAL PLUS 006 NC (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED DUAL 009 NC (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
|
DEVOTED CORE 001 NC (HMO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
DEVOTED GIVEBACK 002 NC (HMO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
DEVOTED GIVEBACK 012 NC (HMO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| DEVOTED CORE 001 NC (HMO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED GIVEBACK 002 NC (HMO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 2 - Generic | — | — | — | None |
|
DEVOTED CHOICE 001 NC (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
DEVOTED CHOICE GIVEBACK 002 NC (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
DEVOTED CHOICE 003 NC (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
DEVOTED CHOICE GIVEBACK 004 NC (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
DEVOTED CHOICE 005 NC (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
DEVOTED CHOICE GIVEBACK 006 NC (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
DEVOTED CHOICE 008 NC (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
DEVOTED CHOICE GIVEBACK 009 NC (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| DEVOTED CHOICE 001 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 002 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE 003 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 004 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE 005 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 006 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE 008 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0009 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0008 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| UHC Dual Complete NC-D001 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0007 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0022 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0021 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0019 (PPO) | Tier 2 - Generic | — | — | — | None |
|
Wellcare Dual Liberty Open (PPO D-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Wellcare Assist Open (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Wellcare Dual Access (HMO-POS D-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Wellcare Dual Liberty (HMO-POS D-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Wellcare Dual Liberty Open (PPO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Wellcare Assist Open (PPO) | Tier 2 - Generic | — | — | — | None |
| Wellcare Dual Access (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| Wellcare Dual Liberty (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
|
Wellcare Dual Reserve (HMO-POS D-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Wellcare Dual Reserve (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0016 (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0004 (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0001 (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage Access from UHC NC-23 (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
UHC Dual Complete NC-S2 (PPO D-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
UHC Dual Complete NC-S001 (PPO D-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0017 (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0016 (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0004 (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0001 (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage Access from UHC NC-23 (PPO) | Tier 2 - Generic | — | — | — | None |
| UHC Dual Complete NC-S2 (PPO D-SNP) | Tier 2 - Generic | — | — | — | None |
| UHC Dual Complete NC-S001 (PPO D-SNP) | Tier 2 - Generic | — | — | — | None |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | Tier 2 - Generic | — | — | — | None |
|
Erickson Advantage Liberty (HMO-POS)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
Erickson Advantage Freedom (HMO-POS)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
Erickson Advantage Guardian (HMO-POS I-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
Aetna Medicare Enhanced (HMO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Aetna Medicare Signature (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Aetna Medicare Enhanced (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Aetna Medicare Enhanced (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Aetna Medicare Signature Extra (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Aetna Medicare Signature (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Aetna Medicare Signature (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Aetna Medicare Signature Giveback (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Aetna Medicare Signature (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Aetna Medicare Signature (HMO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Aetna Medicare Dual (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Aetna Medicare Signature (HMO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Aetna Medicare Value Plus (HMO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Aetna Medicare Prime (HMO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Aetna Medicare Signature Care (HMO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Aetna Medicare Full Dual Care (HMO D-SNP) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Aetna Medicare Enhanced (HMO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Aetna Medicare Enhanced (PPO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Aetna Medicare Enhanced (PPO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Aetna Medicare Signature Extra (PPO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Aetna Medicare Signature Giveback (PPO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
|
Aetna Medicare Full Dual Care (HMO D-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
AARP Medicare Advantage from UHC NC-24 (HMO-POS)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
UHC Dual Complete NC-S3 (HMO-POS D-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
Wellcare Simple Open (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Wellcare Simple (HMO-POS)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Wellcare Simple Open (PPO) | Tier 2 - Generic | — | — | — | None |
| Wellcare Simple (HMO-POS) | Tier 2 - Generic | — | — | — | None |
|
Wellcare Giveback Open (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Wellcare Giveback Open (PPO) | Tier 2 - Generic | — | — | — | None |
|
Blue Medicare PPO Enhanced (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Blue Medicare Essential Plus (HMO-POS)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Blue Medicare Enhanced (HMO-POS)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Blue Medicare Choice (HMO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Blue Medicare Essential (HMO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Experience Health Medicare Advantage (HMO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Healthy Blue + Medicare (HMO-POS D-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Blue Medicare PPO Enhanced (PPO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Blue Medicare Essential Plus (HMO-POS) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Blue Medicare Enhanced (HMO-POS) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Blue Medicare Choice (HMO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Blue Medicare Essential (HMO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Experience Health Medicare Advantage (HMO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Healthy Blue + Medicare (HMO-POS D-SNP) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
|
Alignment Health Platinum (HMO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Alignment Health NC Duals (HMO-POS D-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Alignment Health smartHMO (HMO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Alignment Health Platinum Select (HMO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Alignment Health Heart & Diabetes Care (HMO C-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
Alignment Health AVA (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| Alignment Health Platinum (HMO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Alignment Health NC Duals (HMO-POS D-SNP) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Alignment Health smartHMO (HMO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Alignment Health Platinum Select (HMO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
| Alignment Health AVA (PPO) | Tier 2 - Generic | — | — | ✓ 120 per 30 days | QL |
|
HealthTeam Advantage Plan I (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
HealthTeam Advantage Plan II (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
|
HealthTeam Advantage Vitality Plan (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| HealthTeam Advantage Plan I (PPO) | Tier 2 - Generic | — | — | — | None |
| HealthTeam Advantage Plan II (PPO) | Tier 2 - Generic | — | — | — | None |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 2 - Generic | — | — | — | None |
|
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | ✓ 60 per 30 days | QL |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
|
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0019 (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
|
AARP Medicare Advantage from UHC NC-0017 (PPO)
via BUPROPION HCL SR |
Tier 2 - Generic | — | — | — | None |
| UHC Dual Complete NC-S3 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0015 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| UHC Dual Complete NC-V001 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0012 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0011 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
|
HumanaChoice Giveback H5525-035 (PPO)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
|
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
|
HumanaChoice H5525-049 (PPO)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
|
HumanaChoice H5525-050 (PPO)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
|
HumanaChoice H5525-070 (PPO)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
|
Humana Dual Select H5525-072 (PPO D-SNP)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
|
HumanaChoice H5525-083 (PPO)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
|
Humana Gold Plus H6622-025 (HMO-POS)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
|
Humana Gold Plus H6622-026 (HMO-POS)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
|
Humana Dual Select H6622-027 (HMO-POS D-SNP)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
|
Humana Gold Plus H6622-057 (HMO-POS)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
|
Humana Gold Plus H6622-060 (HMO-POS)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
|
Humana Gold Plus H6622-061 (HMO-POS)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
|
Humana Gold Choice H8145-004 (PFFS)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| Humana Gold Plus H1036-137 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Humana Gold Plus H1036-233 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Humana Dual Select H1036-307 (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Humana Gold Plus Giveback H1036-318 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Humana Gold Plus H1036-335 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| HumanaChoice H5216-211 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Humana Full Access H5525-034 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| HumanaChoice Giveback H5525-035 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| HumanaChoice SNP-DE H5525-036 (PPO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| HumanaChoice H5525-049 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| HumanaChoice H5525-050 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| HumanaChoice H5525-070 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Humana Dual Select H5525-072 (PPO D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| HumanaChoice H5525-083 (PPO) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Humana Gold Plus H6622-025 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Humana Gold Plus H6622-026 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Humana Dual Select H6622-027 (HMO-POS D-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Humana Gold Plus H6622-057 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Humana Gold Plus H6622-060 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Humana Gold Plus H6622-061 (HMO-POS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
| Humana Gold Choice H8145-004 (PFFS) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
|
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
| Humana Gold Plus - Diabetes and Heart (HMO C-SNP) | Tier 3 - Preferred Brand | — | — | ✓ 180 per 30 days | QL |
|
Humana Gold Plus H1036-137 (HMO-POS)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
|
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
|
Humana Gold Plus H1036-233 (HMO-POS)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
|
Humana Dual Select H1036-307 (HMO D-SNP)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
|
Humana Gold Plus Giveback H1036-318 (HMO-POS)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
|
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
|
Humana Gold Plus H1036-335 (HMO-POS)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
|
HumanaChoice Giveback H5216-017 (PPO)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
|
HumanaChoice H5216-211 (PPO)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
|
Humana Full Access H5525-034 (PPO)
via BUPROPION HCL SR |
Tier 3 - Preferred Brand | — | — | ✓ 90 per 30 days | QL |
NC Medicaid PDL
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
NC Medicaid Preferred Drug List 2026
via Forfivo XL |
Non-Preferred | — | — | — | None |
|
NC Medicaid Preferred Drug List 2026
via Wellbutrin SR |
Non-Preferred | — | — | — | None |
|
NC Medicaid Preferred Drug List 2026
via Bupropion Xl |
Non-Preferred | — | — | — | None |
NC State Health Plan
6 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| NC State Health Plan - 70/30 Standard PPO 2026 | Tier 1 - Preferred Generic | — | — | — | None |
| NC State Health Plan - HDHP 2026 | Tier 1 - Preferred Generic | — | — | — | None |
| NC State Health Plan - 80/20 Plus PPO 2026 | Tier 1 - Preferred Generic | — | — | — | None |
|
NC State Health Plan - 80/20 Plus PPO 2026
via bupropion hcl tb24 |
Not Covered | — | — | — | None |
|
NC State Health Plan - 70/30 Standard PPO 2026
via bupropion hcl tb24 |
Not Covered | — | — | — | None |
|
NC State Health Plan - HDHP 2026
via bupropion hcl tb24 |
Not Covered | — | — | — | None |