doxepin hydrochloride

Generic: doxepin hcl

50 MG — Cream

Also known as: Doxepin HCl Topical Cream

Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

Ambetter (Centene)

34 plans

Source: CMS QHP JSON · Formulary date: Jan 1, 2026 · Checked: 16 hours, 49 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Enhanced Asthma/COPD Care Silver $0 Rx Options	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Everyday Bronze	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Elite Bronze	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Clear Silver with $0 Insulin Options	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Signature Expanded Bronze	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Signature Silver	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Signature Gold	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Everyday Bronze with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Complete Gold	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Elite Bronze with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Focused Silver with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Complete Gold with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Signature Expanded Bronze with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Signature Silver with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Signature Gold with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Complete Gold + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Everyday Bronze + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Elite Bronze + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Everyday Bronze with Atrium Health + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Elite Bronze with Atrium Health + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Focused Silver with Atrium Health + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Complete Gold with Atrium Health + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Signature Expanded Bronze + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Signature Silver + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Signature Gold + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Signature Expanded Bronze with Atrium Health + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Signature Silver with Atrium Health + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Signature Gold with Atrium Health + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Enhanced CHF Heart Care Silver $0 Rx Options	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Streamlined Silver with Atrium Health	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Streamlined Silver	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Clear Silver with $0 Insulin Options + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL

AmeriHealth Caritas NC

21 plans

Source: CMS QHP JSON · Formulary date: Sep 22, 2026 · Checked: 16 hours, 49 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 via doxepin hcl	Tier 2 - Generic	—	—	✓	QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via doxepin hcl	Tier 2 - Generic	—	—	✓	QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via doxepin hcl	Tier 2 - Generic	—	—	✓	QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via doxepin hcl	Tier 2 - Generic	—	—	✓	QL
AmeriHealth Caritas Next Silver Premier + No Referrals via doxepin hcl	Tier 2 - Generic	—	—	✓	QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via doxepin hcl	Tier 2 - Generic	—	—	✓	QL
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via doxepin hcl	Tier 2 - Generic	—	—	✓	QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via doxepin hcl	Tier 2 - Generic	—	—	✓	QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via doxepin hcl	Tier 2 - Generic	—	—	✓	QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals via doxepin hcl	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	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 2 - Generic	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	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	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	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Silver Premier + No Referrals	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	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL

Blue Cross Blue Shield Federal

3 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 16 hours, 49 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Basic Option 2026 via doxepin hcl	Tier 1 - Generic	—	—	—	None
BCBS Federal Standard Option 2026 via doxepin hcl	Tier 1 - Generic	—	—	—	None
BCBS Federal Focus 2026 via doxepin hcl	Tier 1 - Generic	—	—	—	None

Blue Cross Blue Shield of NC

10 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 16 hours, 49 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
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 hcl	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026 via doxepin hcl	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Local 2026 via doxepin hcl	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Care 2026 via doxepin hcl	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Value 2026 via doxepin hcl	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Advantage 2026	Tier 2 - Medium Cost Generic/Brand	—	—	—	None

Cigna

20 plans

Source: PDF · Formulary date: Oct 7, 2026 · Checked: 16 hours, 49 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Connect Silver 5000 Indiv Med Deductible via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Bronze 6500 Indiv Med Deductible via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Bronze 5500 Indiv Med Deductible via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Silver 3600 Indiv Med Deductible via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Silver 3000 Indiv Med Deductible via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Bronze CMS Standard via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Silver CMS Standard via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Gold CMS Standard via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓	QL
Connect myDiabetesCare Bronze via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓	QL
Connect myDiabetesCare Silver via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Gold 1500 Indiv Med Deductible via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Bronze RD 5000 Indiv Med Deductible via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Bronze RD 6000 Indiv Med Deductible via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Bronze RD CMS Standard via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Silver RD 3500 Indiv Med Deductible via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Silver RD 5000 Indiv Med Deductible via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Silver RD CMS Standard via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Silver RD 2200 Indiv Med Deductible via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Gold RD CMS Standard via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓	QL
Connect Bronze 7000 HSA Indiv Med Deductible via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓	QL

Medicare Part D

84 plans

Source: CMS QHP JSON · Formulary date: Sep 16, 2026 · Checked: 16 hours, 49 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Longevity Health Plan (HMO I-SNP) via doxepin hcl	Tier 1 - Preferred Generic	—	—	✓ 30 per 30 days	QL
AmeriHealth Caritas VIP Care (HMO D-SNP)	Tier 2 - Generic	✓	—	✓ 90 per 30 days	PA \| QL
Aetna Medicare Signature (HMO) via doxepin hcl	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Aetna Medicare Dual (HMO D-SNP) via doxepin hcl	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (HMO) via doxepin hcl	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
AmeriHealth Caritas VIP Care (HMO D-SNP) via doxepin hcl	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (PPO) via doxepin hcl	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature Giveback (PPO) via doxepin hcl	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (PPO) via doxepin hcl	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (PPO) via doxepin hcl	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature Extra (PPO) via doxepin hcl	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Aetna Medicare Enhanced (PPO) via doxepin hcl	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Aetna Medicare Enhanced (PPO) via doxepin hcl	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (PPO) via doxepin hcl	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via doxepin hcl	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Troy Medicare (HMO) via doxepin hcl	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Troy Medicare (HMO)	Tier 2 - Generic	✓	—	✓ 45 per 30 days	PA \| QL
Aetna Medicare Chronic Care Value (HMO C-SNP) via doxepin hcl	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Aetna Medicare Enhanced (HMO) via doxepin hcl	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)	Tier 2 - Generic	✓	—	✓ 45 per 30 days	PA \| QL
Aetna Medicare Chronic Care (HMO C-SNP) via doxepin hcl	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Aetna Medicare Full Dual Care (HMO D-SNP) via doxepin hcl	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature Care (HMO) via doxepin hcl	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Aetna Medicare Value Plus (HMO) via doxepin hcl	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
Aetna Medicare Prime (HMO) via doxepin hcl	Tier 2 - Generic	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE 005 NC (PPO) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE 008 NC (PPO) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HealthSpring TotalCare (HMO D-SNP) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
HealthSpring TotalCare Plus (HMO D-SNP) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Alignment Health Platinum (HMO) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Alignment Health NC Duals (HMO-POS D-SNP) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Alignment Health smartHMO (HMO) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Alignment Health Platinum Select (HMO) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CORE 001 NC (HMO) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED GIVEBACK 002 NC (HMO) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED DUAL 009 NC (HMO D-SNP) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED GIVEBACK 012 NC (HMO) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Alignment Health AVA (PPO) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE 001 NC (PPO) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE 003 NC (PPO) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via doxepin hcl	Tier 3 - Preferred Brand	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature Care (HMO)	Tier 4 - Non-Preferred	✓	—	✓ 45 per 30 days	PA \| QL
HealthSpring Preferred Plus (HMO) via doxepin hcl	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
HealthSpring Preferred Savings (HMO) via doxepin hcl	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
HealthSpring Preferred Select (HMO) via doxepin hcl	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
HealthSpring Preferred (HMO) via doxepin hcl	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
HealthSpring True Choice (PPO) via doxepin hcl	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Prime (HMO)	Tier 4 - Non-Preferred	✓	—	✓ 45 per 30 days	PA \| QL
Aetna Medicare Value Plus (HMO)	Tier 4 - Non-Preferred	✓	—	✓ 45 per 30 days	PA \| QL
Aetna Medicare Signature (HMO)	Tier 4 - Non-Preferred	✓	—	✓ 45 per 30 days	PA \| QL
Aetna Medicare Dual (HMO D-SNP)	Tier 4 - Non-Preferred	✓	—	✓ 45 per 30 days	PA \| QL
Aetna Medicare Signature (HMO)	Tier 4 - Non-Preferred	✓	—	✓ 45 per 30 days	PA \| QL
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	✓	—	✓ 45 per 30 days	PA \| QL
Aetna Medicare Signature Extra (PPO)	Tier 4 - Non-Preferred	✓	—	✓ 45 per 30 days	PA \| QL
Aetna Medicare Enhanced (PPO)	Tier 4 - Non-Preferred	✓	—	✓ 45 per 30 days	PA \| QL
Wellcare Simple Open (PPO) via doxepin hcl	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Wellcare Dual Liberty Open (PPO D-SNP) via doxepin hcl	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Wellcare Assist Open (PPO) via doxepin hcl	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Wellcare Giveback Open (PPO) via doxepin hcl	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	✓	—	✓ 45 per 30 days	PA \| QL
Aetna Medicare Signature Giveback (PPO)	Tier 4 - Non-Preferred	✓	—	✓ 45 per 30 days	PA \| QL
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	✓	—	✓ 45 per 30 days	PA \| QL
Wellcare Dual Liberty (HMO-POS D-SNP) via doxepin hcl	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Aetna Medicare Full Dual Care (HMO D-SNP)	Tier 4 - Non-Preferred	✓	—	✓ 45 per 30 days	PA \| QL
Aetna Medicare Chronic Care Value (HMO C-SNP)	Tier 4 - Non-Preferred	✓	—	✓ 45 per 30 days	PA \| QL
Aetna Medicare Enhanced (PPO)	Tier 4 - Non-Preferred	✓	—	✓ 45 per 30 days	PA \| QL
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	✓	—	✓ 45 per 30 days	PA \| QL
Aetna Medicare Enhanced (HMO)	Tier 4 - Non-Preferred	✓	—	✓ 45 per 30 days	PA \| QL
Aetna Medicare Chronic Care (HMO C-SNP)	Tier 4 - Non-Preferred	✓	—	✓ 45 per 30 days	PA \| QL
Wellcare Simple (HMO-POS) via doxepin hcl	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Wellcare Dual Access (HMO-POS D-SNP) via doxepin hcl	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL
Wellcare Dual Reserve (HMO-POS D-SNP) via doxepin hcl	Tier 4 - Non-Preferred	—	—	✓ 30 per 30 days	QL

NC State Health Plan

3 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 16 hours, 49 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - 80/20 Plus PPO 2026 via doxepin hcl	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via doxepin hcl	Tier 1 - Preferred Generic	—	—	—	None
NC State Health Plan - HDHP 2026 via doxepin hcl	Tier 1 - Preferred Generic	—	—	—	None

Oscar Health

28 plans

Source: CMS QHP JSON · Checked: 16 hours, 49 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Silver Simple Diabetes \| with Atrium Health	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Gold Elite Saver Plus \| with Atrium Health	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Bronze Simple Diabetes \| with Atrium Health	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Silver Simple Chronic Care CKM \| with Atrium Health	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AIAN Cost Share	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
AIAN Cost Share \| with Atrium Health	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Bronze Elite + PCP Saver Plus	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Secure	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Bronze Classic 4700	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Silver Simple PCP Saver	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Gold Elite Saver Plus	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Silver Simple Diabetes	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Bronze Classic Standard	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Silver Classic Standard	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Gold Classic Standard	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Bronze Classic Standard \| with Atrium Health	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Silver Classic Standard \| with Atrium Health	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Gold Classic Standard \| with Atrium Health	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Bronze Simple Chronic Care CKM \| with Atrium Health	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Secure \| with Atrium Health	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Bronze Classic 4700 \| with Atrium Health	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Bronze Elite + PCP Saver Plus \| with Atrium Health	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Silver Classic \| with Atrium Health	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Silver Simple PCP Saver \| with Atrium Health	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL
Silver Classic	Tier 4 - Non-Preferred	—	✓	✓	ST \| QL

TRICARE

1 plan

Source: Excel (XLSX) · Formulary date: Jul 31, 2026 · Checked: 16 hours, 49 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026 via doxepin hcl	Tier 1 - Basic Core Formulary	—	—	—	None

UnitedHealthcare

17 plans

Source: PDF · Formulary date: Sep 23, 2026 · Checked: 16 hours, 49 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals)	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)	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)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL