doxepin hcl

10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg — Capsule

GENITOURINARY AGENTS - MISC.

Also known as: doxepin hcl oral capsule doxepin hcl oral concentrate doxepin hcl oral tablet doxepin hcl caps 10mg, 25mg, 50mg, 75mg, 100mg, 150mg; conc 10mg/ml doxepin hcl cap 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg doxepin hcl caps 10mg, 25mg, 50mg, 75mg, Doxepin HCl Oral Capsule Doxepin HCl Oral Concentrate Doxepin HCl Oral Tablet doxepin hcl cap 10 mg, 25 mg, 50 mg, 75 mg, 100 mg
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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: 6 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Enhanced Asthma/COPD Care Silver $0 Rx Options
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Everyday Bronze
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Elite Bronze
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Expanded Bronze
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Silver
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Gold
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Complete Gold
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Elite Bronze with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Focused Silver with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Complete Gold with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Expanded Bronze with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Silver with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Gold with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Complete Gold + Vision + Adult Dental
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Everyday Bronze + Vision + Adult Dental
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Elite Bronze + Vision + Adult Dental
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Everyday Bronze with Atrium Health + Vision + Adult Dental
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Elite Bronze with Atrium Health + Vision + Adult Dental
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Focused Silver with Atrium Health + Vision + Adult Dental
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Complete Gold with Atrium Health + Vision + Adult Dental
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Expanded Bronze + Vision + Adult Dental
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Silver + Vision + Adult Dental
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Gold + Vision + Adult Dental
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Silver with Atrium Health + Vision + Adult Dental
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Signature Gold with Atrium Health + Vision + Adult Dental
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Enhanced CHF Heart Care Silver $0 Rx Options
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Streamlined Silver with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Streamlined Silver
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 6 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via doxepin hydrochloride 		Tier 2 - Generic — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via doxepin hydrochloride 		Tier 2 - Generic — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Premier + No Referrals
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 6 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Basic Option 2026 Tier 1 - Generic — — — None
BCBS Federal Standard Option 2026 Tier 1 - Generic — — — None
BCBS Federal Focus 2026 Tier 1 - Generic — — — None
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 6 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Home with UNC Health Alliance 2026
via doxepin hydrochloride 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Local 2026
via doxepin hydrochloride 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Care 2026
via doxepin hydrochloride 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Value 2026
via doxepin hydrochloride 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Advantage 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Local 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Care 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Value 2026 Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Advantage 2026
via doxepin hydrochloride 		Tier 2 - Medium Cost Generic/Brand — — — None
Source: PDF  ·  Formulary date: Oct 7, 2026  ·  Checked: 6 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver 5000 Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 6500 Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 5500 Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 3600 Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 3000 Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze CMS Standard Tier 3 - Preferred Brand — — ✓ QL
Connect Silver CMS Standard Tier 3 - Preferred Brand — — ✓ QL
Connect Gold CMS Standard Tier 3 - Preferred Brand — — ✓ QL
Connect myDiabetesCare Bronze Tier 3 - Preferred Brand — — ✓ QL
Connect myDiabetesCare Silver Tier 3 - Preferred Brand — — ✓ QL
Connect Gold 1500 Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD 5000 Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD 6000 Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD CMS Standard Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 3500 Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 5000 Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD CMS Standard Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 2200 Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Connect Gold RD CMS Standard Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 7000 HSA Indiv Med Deductible Tier 3 - Preferred Brand — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 6 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic — — ✓ 30 per 30 days QL
AmeriHealth Caritas VIP Care (HMO D-SNP)
via doxepin hydrochloride 		Tier 2 - Generic ✓ — ✓ 90 per 30 days PA | QL
Aetna Medicare Signature (HMO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Dual (HMO D-SNP) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Signature (HMO) Tier 2 - Generic — — ✓ 30 per 30 days QL
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Signature Giveback (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Signature Extra (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Enhanced (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic — — ✓ 30 per 30 days QL
Troy Medicare (HMO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Troy Medicare (HMO)
via doxepin hydrochloride 		Tier 2 - Generic ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Enhanced (HMO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via doxepin hydrochloride 		Tier 2 - Generic ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Chronic Care (HMO C-SNP) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Signature Care (HMO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Value Plus (HMO) Tier 2 - Generic — — ✓ 30 per 30 days QL
Aetna Medicare Prime (HMO) Tier 2 - Generic — — ✓ 30 per 30 days QL
DEVOTED CHOICE 005 NC (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED CHOICE 008 NC (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HealthSpring TotalCare (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
HealthSpring TotalCare Plus (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Alignment Health Platinum (HMO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Alignment Health NC Duals (HMO-POS D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Alignment Health smartHMO (HMO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Alignment Health Platinum Select (HMO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED CORE 001 NC (HMO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED GIVEBACK 002 NC (HMO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED DUAL 009 NC (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED GIVEBACK 012 NC (HMO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Alignment Health AVA (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED CHOICE 001 NC (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED CHOICE 003 NC (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) Tier 3 - Preferred Brand — — ✓ 30 per 30 days QL
Aetna Medicare Signature Care (HMO)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
HealthSpring Preferred Plus (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthSpring Preferred Savings (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthSpring Preferred Select (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthSpring Preferred (HMO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
HealthSpring True Choice (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Prime (HMO)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Value Plus (HMO)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Signature (HMO)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Dual (HMO D-SNP)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Signature (HMO)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Signature Extra (PPO)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Enhanced (PPO)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Wellcare Simple Open (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Dual Liberty Open (PPO D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Assist Open (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Giveback Open (PPO) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Signature (PPO)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Signature Giveback (PPO)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Wellcare Dual Liberty (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Aetna Medicare Full Dual Care (HMO D-SNP)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Chronic Care Value (HMO C-SNP)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Enhanced (PPO)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Signature (PPO)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Enhanced (HMO)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Aetna Medicare Chronic Care (HMO C-SNP)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ 45 per 30 days PA | QL
Wellcare Simple (HMO-POS) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Dual Access (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 4 - Non-Preferred — — ✓ 30 per 30 days QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 6 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 80/20 Plus PPO 2026 Tier 1 - Preferred Generic — — — None
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
Source: CMS QHP JSON  ·  Checked: 6 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Silver Simple Diabetes | with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Gold Elite Saver Plus | with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Bronze Simple Diabetes | with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Silver Simple Chronic Care CKM | with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AIAN Cost Share
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AIAN Cost Share | with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Bronze Elite + PCP Saver Plus
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Secure
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Bronze Classic 4700
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Silver Simple PCP Saver
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Gold Elite Saver Plus
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Silver Simple Diabetes
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Bronze Classic Standard
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Silver Classic Standard
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Gold Classic Standard
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Bronze Classic Standard | with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Silver Classic Standard | with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Gold Classic Standard | with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Bronze Simple Chronic Care CKM | with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Secure | with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Bronze Classic 4700 | with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Bronze Elite + PCP Saver Plus | with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Silver Classic | with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Silver Simple PCP Saver | with Atrium Health
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Silver Classic
via doxepin hydrochloride 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Source: Excel (XLSX)  ·  Formulary date: Jul 31, 2026  ·  Checked: 6 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026 Tier 1 - Basic Core Formulary — — — None
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 6 hours, 14 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via doxepin hydrochloride 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
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