bupropion hcl

100 mg, 150 mg, 300 mg, 450 mg, 75 mg — Tablet

ANTIDEPRESSANTS

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.
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 10 hours, 6 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 10 hours, 6 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Standard Option 2026 Tier 1 - Generic — — — None
BCBS Federal Basic Option 2026 Tier 1 - Generic — — — None
BCBS Federal Focus 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
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 10 hours, 6 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Home with UNC Health Alliance 2026
via Wellbutrin Xl 		Tier 1 - Lowest Cost Generic — — — None
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
BCBSNC Blue Care 2026
via Wellbutrin Xl 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Value 2026
via Wellbutrin Xl 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026
via Wellbutrin SR 		Tier 1 - Lowest Cost Generic — — ✓ QL
BCBSNC Blue Value 2026
via Wellbutrin SR 		Tier 1 - Lowest Cost Generic — — ✓ QL
BCBSNC Blue Value 2026 Tier 1 - Lowest Cost Generic — — ✓ QL
BCBSNC Blue Local 2026 Tier 1 - Lowest Cost Generic — — ✓ QL
BCBSNC Blue Care 2026 Tier 1 - Lowest Cost Generic — — ✓ QL
BCBSNC Blue Advantage 2026
via Wellbutrin Xl 		Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Advantage 2026 Tier 1 - Lowest Cost Generic — — ✓ QL
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 1 - Lowest Cost Generic — — ✓ QL
BCBSNC Blue Local 2026
via Wellbutrin Xl 		Tier 1 - Lowest Cost Generic — — — None
Source: PDF  ·  Formulary date: Oct 7, 2026  ·  Checked: 10 hours, 6 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Bronze RD 5000 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Bronze RD 6000 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Bronze RD CMS Standard Tier 2 - Generic — — ✓ QL
Connect Silver RD 3500 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Silver RD 5000 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Silver RD CMS Standard Tier 2 - Generic — — ✓ QL
Connect Silver RD 2200 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Gold RD CMS Standard Tier 2 - Generic — — ✓ QL
Connect Bronze 7000 HSA Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Bronze RD 5000 Indiv Med Deductible
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ QL
Connect Bronze CMS Standard
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ QL
Connect Silver 3000 Indiv Med Deductible
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ QL
Connect Silver 3600 Indiv Med Deductible
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ QL
Connect Silver 5000 Indiv Med Deductible
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ QL
Connect Bronze RD CMS Standard
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ QL
Connect Bronze RD 6000 Indiv Med Deductible
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ QL
Connect Bronze 5500 Indiv Med Deductible
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ QL
Connect Bronze 6500 Indiv Med Deductible
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ QL
Connect Bronze 7000 HSA Indiv Med Deductible
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ QL
Connect Gold RD CMS Standard
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ QL
Connect Silver RD 2200 Indiv Med Deductible
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ QL
Connect Silver RD CMS Standard
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ QL
Connect Silver RD 5000 Indiv Med Deductible
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ QL
Connect Silver CMS Standard
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ QL
Connect Gold 1500 Indiv Med Deductible
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ QL
Connect Silver RD 3500 Indiv Med Deductible
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ QL
Connect myDiabetesCare Silver
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ QL
Connect myDiabetesCare Bronze
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ QL
Connect Gold CMS Standard
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ QL
Connect Bronze 6500 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Bronze 5500 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Silver 5000 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Silver 3600 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Silver 3000 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Connect Bronze CMS Standard Tier 2 - Generic — — ✓ QL
Connect Silver CMS Standard Tier 2 - Generic — — ✓ QL
Connect Gold CMS Standard Tier 2 - Generic — — ✓ QL
Connect myDiabetesCare Bronze Tier 2 - Generic — — ✓ QL
Connect myDiabetesCare Silver Tier 2 - Generic — — ✓ QL
Connect Gold 1500 Indiv Med Deductible Tier 2 - Generic — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 10 hours, 6 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
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
Longevity Health Plan (HMO I-SNP)
via BUPROPION HCL SR 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 1 - Preferred Generic — — — None
Troy Medicare (HMO) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
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)
via BUPROPION HCL SR 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Senior Care (HMO I-SNP) Tier 1 - Preferred Generic — — — None
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP)
via BUPROPION HCL SR 		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
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
via BUPROPION HCL SR 		Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage (HMO C-SNP)
via BUPROPION HCL SR 		Tier 1 - Preferred Generic — — — None
Senior Care (HMO I-SNP)
via BUPROPION HCL SR 		Tier 1 - Preferred Generic — — — None
NHC Advantage (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
AmeriHealth Caritas VIP Care (HMO D-SNP)
via BUPROPION HCL SR 		Tier 1 - Preferred Generic — — ✓ 60 per 30 days QL
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage (HMO C-SNP) Tier 1 - Preferred Generic — — — None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic — — — None
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
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
Alignment Health Platinum (HMO)
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ 60 per 30 days QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 2 - Generic — — — None
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 2 - Generic — — — None
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 2 - Generic — — — None
Wellcare Simple Open (PPO) Tier 2 - Generic — — — None
Wellcare Dual Liberty Open (PPO D-SNP) Tier 2 - Generic — — — None
Wellcare Assist Open (PPO) Tier 2 - Generic — — — None
Wellcare Giveback Open (PPO) Tier 2 - Generic — — — None
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 2 - Generic — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 2 - Generic — — — None
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 Chronic Care (HMO C-SNP) Tier 2 - Generic — — ✓ 120 per 30 days QL
Aetna Medicare Enhanced (HMO) Tier 2 - Generic — — ✓ 120 per 30 days QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 2 - Generic — — ✓ 120 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
Wellcare Simple (HMO-POS) Tier 2 - Generic — — — None
Wellcare Dual Access (HMO-POS D-SNP) Tier 2 - Generic — — — None
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 2 - Generic — — — None
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0021 (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-0007 (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-0008 (HMO-POS) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 2 - Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 2 - Generic — — — None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 2 - Generic — — — None
UHC Dual Complete NC-V001 (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-S3 (HMO-POS D-SNP) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 2 - Generic — — — None
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 2 - Generic — — — None
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 2 - Generic — — — None
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 2 - Generic — — — None
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
DEVOTED CORE 001 NC (HMO) Tier 2 - Generic — — — None
DEVOTED GIVEBACK 002 NC (HMO) Tier 2 - Generic — — — None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 2 - Generic — — — None
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 2 - Generic — — — None
DEVOTED GIVEBACK 012 NC (HMO) Tier 2 - Generic — — — None
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 (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 Signature (PPO) Tier 2 - Generic — — ✓ 120 per 30 days QL
Erickson Advantage Signature (HMO-POS) Tier 2 - Generic — — — None
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 2 - Generic — — — None
Erickson Advantage Champion (HMO-POS C-SNP) Tier 2 - Generic — — — None
Erickson Advantage Freedom (HMO-POS) Tier 2 - Generic — — — None
Erickson Advantage Liberty (HMO-POS) Tier 2 - Generic — — — None
Alignment Health AVA (PPO) Tier 2 - Generic — — ✓ 120 per 30 days QL
HealthSpring True Choice (PPO) Tier 2 - Generic — — ✓ 120 per 30 days QL
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 2 - Generic — — ✓ 120 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
HealthSpring TotalCare (HMO D-SNP) Tier 2 - Generic — — ✓ 120 per 30 days QL
HealthSpring Preferred (HMO) Tier 2 - Generic — — ✓ 120 per 30 days QL
HealthSpring TotalCare Plus (HMO D-SNP) Tier 2 - Generic — — ✓ 120 per 30 days QL
AARP Medicare Advantage from UHC NC-0012 (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 Giveback from UHC NC-14 (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 from UHC NC-0015 (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-24 (HMO-POS)
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
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
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-28 (HMO-POS C-SNP)
via BUPROPION HCL SR 		Tier 2 - Generic — — — None
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
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 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 GIVEBACK 012 NC (HMO)
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ 60 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
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
Erickson Advantage Signature (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
Erickson Advantage Champion (HMO-POS C-SNP)
via BUPROPION HCL SR 		Tier 2 - Generic — — — None
Erickson Advantage Freedom (HMO-POS)
via BUPROPION HCL SR 		Tier 2 - Generic — — — None
Erickson Advantage Liberty (HMO-POS)
via BUPROPION HCL SR 		Tier 2 - Generic — — — None
Alignment Health AVA (PPO)
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ 60 per 30 days QL
HealthSpring True Choice (PPO)
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
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
HealthSpring TotalCare (HMO D-SNP)
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ 60 per 30 days QL
HealthSpring Preferred (HMO)
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 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
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
UHC Nursing Home Plan NC-F001 (PPO I-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 Dual Complete NC-S2 (PPO D-SNP)
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 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 Giveback Open (PPO)
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ 60 per 30 days QL
AARP Medicare Advantage Access from UHC NC-23 (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 from UHC NC-0004 (PPO)
via BUPROPION HCL SR 		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-0017 (PPO)
via BUPROPION HCL SR 		Tier 2 - Generic — — — None
AARP Medicare Advantage from UHC NC-0019 (PPO)
via BUPROPION HCL SR 		Tier 2 - Generic — — — None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
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
Aetna Medicare Dual (HMO D-SNP)
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
Aetna Medicare Value Plus (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 Signature Care (HMO)
via BUPROPION HCL SR 		Tier 2 - Generic — — ✓ 60 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP)
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 Enhanced (HMO)
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
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
Wellcare Simple (HMO-POS)
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 Reserve (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
AARP Medicare Advantage from UHC NC-0021 (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-0007 (HMO-POS)
via BUPROPION HCL SR 		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-0008 (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-0011 (HMO-POS)
via BUPROPION HCL SR 		Tier 2 - Generic — — — None
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
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 - Diabetes and Heart (HMO C-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 H5525-083 (PPO)
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 Dual Select H1036-307 (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 Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
Humana Gold Plus H1036-137 (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 H6622-061 (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 H1036-335 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 180 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 Gold Plus SNP-DE H1036-331 (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 Full Access H5525-034 (PPO)
via BUPROPION HCL SR 		Tier 3 - Preferred Brand — — ✓ 90 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
Humana Gold Plus H6622-057 (HMO-POS) Tier 3 - Preferred Brand — — ✓ 180 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 Plus H6622-026 (HMO-POS) 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 Choice H8145-004 (PFFS)
via BUPROPION HCL SR 		Tier 3 - Preferred Brand — — ✓ 90 per 30 days QL
Humana Dual Select H6622-027 (HMO-POS 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 Dual Select H5525-072 (PPO D-SNP) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
HumanaChoice H5525-070 (PPO) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
HumanaChoice H5525-050 (PPO) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
HumanaChoice H5525-049 (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 Giveback H5525-035 (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 H5216-211 (PPO) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
HumanaChoice Giveback H5216-017 (PPO) Tier 3 - Preferred Brand — — ✓ 180 per 30 days QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 10 hours, 6 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026
via Wellbutrin SR 		Non-Preferred — — — None
NC Medicaid Preferred Drug List 2026
via Forfivo XL 		Non-Preferred — — — None
NC Medicaid Preferred Drug List 2026
via Bupropion Xl 		Non-Preferred — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 10 hours, 6 minutes ago
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 - 70/30 Standard PPO 2026
via bupropion hcl tb24 		Not Covered — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via bupropion hcl tb24 		Not Covered — — — None
NC State Health Plan - HDHP 2026
via bupropion hcl tb24 		Not Covered — — — None
Source: Excel (XLSX)  ·  Formulary date: Jul 31, 2026  ·  Checked: 10 hours, 6 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026 Tier 1 - Basic Core Formulary ✓ — — PA
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