doxycycline hyclate

Generic: Doxy

100 mg, 150 mg, 200 mg, 50 mg, 60 mg, 75 mg, 80 mg — Capsule

Also known as: doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 Doryx DR doxycycline hyclate cap 50 mg doxycycline hyclate cap 100 mg doxycycline hyclate tab 20 mg, 100 mg Doxycycline Hyclate 50 Mg Capsule Doxycycline Hyclate 100 Mg Capsule Doxycycline Hyclate 20 Mg Tablet Doxycycline Hyclate 100 Mg Tablet doxycycline hyclate caps 50mg, 100mg; solr 100mg; tabs 20mg, 100mg doxycycline hyclate tabs 50mg, 75mg, 150mg; tbec 50mg, 75mg, 80mg, 100mg, 150mg, 200mg doxycycline hyclate caps 50mg, 100mg; tabs 50mg, 75mg, 100mg, 150mg; tbec 50mg, 75mg, 100mg, 150mg, 200mg DORYX MPC VIBRAMYCIN DORYX TARGADOX LYMEPAK MORGIDOX doxycycline hyclate caps 50mg, 100mg; solr doxycycline hyclate tabs 50mg, 75mg, 150mg;

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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.

Ambetter (Centene)

29 plans

Source: CMS QHP JSON · Formulary date: Jan 1, 2026 · Checked: 5 hours, 15 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Everyday Bronze with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	✓	QL
Standard Silver + Vision + Adult Dental	Tier 2 - Generic	—	—	✓	QL
Standard Expanded Bronze + Vision + Adult Dental	Tier 2 - Generic	—	—	✓	QL
Complete Gold with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	✓	QL
Focused Silver with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	✓	QL
Standard Gold	Tier 2 - Generic	—	—	✓	QL
Everyday Bronze with Atrium Health	Tier 2 - Generic	—	—	✓	QL
Elite Bronze with Atrium Health	Tier 2 - Generic	—	—	✓	QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental	Tier 2 - Generic	—	—	✓	QL
Complete Gold + Vision + Adult Dental	Tier 2 - Generic	—	—	✓	QL
Everyday Bronze + Vision + Adult Dental	Tier 2 - Generic	—	—	✓	QL
Elite Bronze + Vision + Adult Dental	Tier 2 - Generic	—	—	✓	QL
Elite Bronze with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	✓	QL
Focused Silver with Atrium Health	Tier 2 - Generic	—	—	✓	QL
Complete Gold with Atrium Health	Tier 2 - Generic	—	—	✓	QL
Standard Expanded Bronze with Atrium Health	Tier 2 - Generic	—	—	✓	QL
Standard Silver with Atrium Health	Tier 2 - Generic	—	—	✓	QL
Standard Gold with Atrium Health	Tier 2 - Generic	—	—	✓	QL
Standard Gold + Vision + Adult Dental	Tier 2 - Generic	—	—	✓	QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	✓	QL
Standard Silver with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	✓	QL
Standard Gold with Atrium Health + Vision + Adult Dental	Tier 2 - Generic	—	—	✓	QL
Complete Gold	Tier 2 - Generic	—	—	✓	QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options	Tier 2 - Generic	—	—	✓	QL
Everyday Bronze	Tier 2 - Generic	—	—	✓	QL
Elite Bronze	Tier 2 - Generic	—	—	✓	QL
Clear Silver with $0 Insulin Options	Tier 2 - Generic	—	—	✓	QL
Standard Expanded Bronze	Tier 2 - Generic	—	—	✓	QL
Standard Silver	Tier 2 - Generic	—	—	✓	QL

Blue Cross Blue Shield Federal

3 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 5 hours, 15 minutes ago

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

Blue Cross Blue Shield of NC

10 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 5 hours, 15 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBSNC Blue Value 2026	Tier 1 - Lowest Cost Generic	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026	Tier 1 - Lowest Cost Generic	—	—	—	None
BCBSNC Blue Advantage 2026	Tier 1 - Lowest Cost Generic	—	—	—	None
BCBSNC Blue Local 2026	Tier 1 - Lowest Cost Generic	—	—	—	None
BCBSNC Blue Care 2026	Tier 1 - Lowest Cost Generic	—	—	—	None
BCBSNC Blue Value 2026 via Vibramycin	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Advantage 2026 via Vibramycin	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Home with UNC Health Alliance 2026 via Vibramycin	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Local 2026 via Vibramycin	Tier 2 - Medium Cost Generic/Brand	—	—	—	None
BCBSNC Blue Care 2026 via Vibramycin	Tier 2 - Medium Cost Generic/Brand	—	—	—	None

Cigna

1 plan

Source: PDF · Formulary date: Jan 1, 2026 · Checked: 5 hours, 15 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Cigna Plus NC 4-Tier Formulary 2026	Tier 1 - Generic	—	—	—	None

Medicare Part D

273 plans

Source: CMS QHP JSON · Formulary date: Mar 18, 2026 · Checked: 5 hours, 15 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
PruittHealth Premier (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) via Doxy	Tier 1 - Preferred Generic	—	—	—	None
Liberty Medicare Dual Plan (HMO D-SNP) via Doxy	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
Provider Partners North Carolina Advantage 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 Essential Plan (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
Longevity Health Plan (HMO I-SNP)	Tier 1 - Preferred Generic	✓	—	—	PA
Longevity Health Plan (HMO I-SNP) via Doxy	Tier 1 - Preferred Generic	✓	—	—	PA
NHC Advantage (HMO I-SNP)	Tier 1 - Preferred Generic	—	—	—	None
PruittHealth Premier (HMO I-SNP) via Doxy	Tier 1 - Preferred Generic	—	—	—	None
NHC Advantage (HMO I-SNP) via Doxy	Tier 1 - Preferred Generic	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP)	Tier 2 - Generic	—	—	—	None
Senior Care (HMO I-SNP) via Doxy	Tier 2 - Generic	—	—	—	None
Senior Care (HMO I-SNP)	Tier 2 - Generic	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP) via Doxy	Tier 2 - Generic	—	—	—	None
Liberty Medicare Advantage (HMO C-SNP)	Tier 2 - Generic	—	—	—	None
Wellcare Simple Open (PPO) via Doxy	Tier 2 - Generic	—	—	—	None
Wellcare Simple (HMO-POS) via Doxy	Tier 2 - Generic	—	—	—	None
Wellcare Simple Open (PPO)	Tier 2 - Generic	—	—	—	None
Wellcare Simple (HMO-POS)	Tier 2 - Generic	—	—	—	None
Wellcare Giveback Open (PPO) via Doxy	Tier 2 - Generic	—	—	—	None
Wellcare Giveback Open (PPO)	Tier 2 - Generic	—	—	—	None
Troy Medicare (HMO) via Doxy	Tier 2 - Generic	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Doxy	Tier 2 - Generic	—	—	—	None
Troy Medicare (HMO)	Tier 2 - Generic	—	—	—	None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas VIP Care (HMO D-SNP) via Doxy	Tier 2 - Generic	—	—	—	None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H1036-137 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H1036-233 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
Humana Dual Select H1036-307 (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus Giveback H1036-318 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H1036-335 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice Giveback H5216-017 (PPO)	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice H5216-211 (PPO)	Tier 3 - Preferred Brand	—	—	—	None
Humana Full Access H5525-034 (PPO)	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO)	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice H5525-049 (PPO)	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice H5525-050 (PPO)	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice H5525-070 (PPO)	Tier 3 - Preferred Brand	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
HumanaChoice H5525-083 (PPO)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H6622-025 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
Humana Dual Select H6622-027 (HMO-POS D-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H6622-057 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H6622-060 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus H6622-061 (HMO-POS)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Choice H8145-004 (PFFS)	Tier 3 - Preferred Brand	—	—	—	None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)	Tier 3 - Preferred Brand	—	—	—	None
Wellcare Dual Reserve (HMO-POS D-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (HMO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Dual (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (HMO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Value Plus (HMO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Prime (HMO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature Care (HMO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Full Dual Care (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Enhanced (HMO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Enhanced (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Enhanced (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature Extra (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature Giveback (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Chronic Care (HMO C-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Chronic Care Value (HMO C-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Chronic Care (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Chronic Care Value (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Freedom (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Guardian (HMO-POS I-SNP)	Tier 4 - Non-Preferred	—	—	—	None
HealthSpring True Choice (PPO) via Doxy	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring True Choice (PPO)	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring TotalCare (HMO D-SNP) via Doxy	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring TotalCare Plus (HMO D-SNP) via Doxy	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring TotalCare (HMO D-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring TotalCare Plus (HMO D-SNP)	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring Preferred (HMO) via Doxy	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring Preferred Select (HMO) via Doxy	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring Preferred Savings (HMO) via Doxy	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring Preferred Plus (HMO) via Doxy	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring Preferred (HMO)	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring Preferred Select (HMO)	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring Preferred Savings (HMO)	Tier 4 - Non-Preferred	✓	—	—	PA
HealthSpring Preferred Plus (HMO)	Tier 4 - Non-Preferred	✓	—	—	PA
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED DUAL FULL 013 NC (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED DUAL PLUS 006 NC (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED DUAL 009 NC (HMO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CORE 001 NC (HMO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CORE 001 NC (HMO)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED GIVEBACK 002 NC (HMO)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED GIVEBACK 012 NC (HMO)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Enhanced (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Enhanced (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature Extra (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature Giveback (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Signature (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-26 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-24 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-S3 (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-V001 (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 001 NC (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 003 NC (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 005 NC (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 008 NC (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-D001 (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0019 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0017 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0016 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0004 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0001 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Access from UHC NC-23 (PPO)	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-S2 (PPO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-S001 (PPO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
UHC Nursing Home Plan NC-F001 (PPO I-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Liberty (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Freedom (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Guardian (HMO-POS I-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Signature (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 001 NC (PPO)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 002 NC (PPO)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 003 NC (PPO)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 004 NC (PPO)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 005 NC (PPO)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 006 NC (PPO)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE 008 NC (PPO)	Tier 4 - Non-Preferred	—	—	—	None
DEVOTED CHOICE GIVEBACK 009 NC (PPO)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-26 (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-24 (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-S3 (HMO-POS D-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-V001 (HMO-POS D-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-D001 (HMO-POS D-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0019 (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare PPO Enhanced (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Essential Plus (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Enhanced (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Choice (HMO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Essential (HMO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Experience Health Medicare Advantage (HMO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare PPO Enhanced (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Essential Plus (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Enhanced (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Choice (HMO)	Tier 4 - Non-Preferred	—	—	—	None
Blue Medicare Essential (HMO)	Tier 4 - Non-Preferred	—	—	—	None
Experience Health Medicare Advantage (HMO)	Tier 4 - Non-Preferred	—	—	—	None
Healthy Blue + Medicare (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Platinum (HMO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health smartHMO (HMO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Platinum Select (HMO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health AVA (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Platinum (HMO)	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health NC Duals (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health smartHMO (HMO)	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Platinum Select (HMO)	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health Heart & Diabetes Care (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Alignment Health AVA (PPO)	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan I (PPO)	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Plan II (PPO)	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Vitality Plan (PPO)	Tier 4 - Non-Preferred	—	—	—	None
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0017 (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0016 (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0004 (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage from UHC NC-0001 (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
AARP Medicare Advantage Access from UHC NC-23 (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-S2 (PPO D-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty Open (PPO D-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Assist Open (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Access (HMO-POS D-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty Open (PPO D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Assist Open (PPO)	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Access (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Liberty (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Wellcare Dual Reserve (HMO-POS D-SNP)	Tier 4 - Non-Preferred	—	—	—	None
UHC Dual Complete NC-S001 (PPO D-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
UHC Nursing Home Plan NC-F001 (PPO I-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus Giveback H1036-318 (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H1036-335 (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice Giveback H5216-017 (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5216-211 (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Humana Full Access H5525-034 (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice Giveback H5525-035 (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-049 (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-050 (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-070 (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Humana Dual Select H5525-072 (PPO D-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
HumanaChoice H5525-083 (PPO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-025 (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-026 (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Humana Dual Select H6622-027 (HMO-POS D-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-057 (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-060 (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H6622-061 (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Choice H8145-004 (PFFS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H1036-137 (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Humana Gold Plus H1036-233 (HMO-POS) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Humana Dual Select H1036-307 (HMO D-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Champion (HMO-POS C-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
UHC Complete Care NC-25 (HMO-POS C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
UHC Complete Care NC-27 (HMO-POS C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
UHC Complete Care NC-28 (HMO-POS C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Champion (HMO-POS C-SNP)	Tier 4 - Non-Preferred	—	—	—	None
UHC Complete Care NC-28 (HMO-POS C-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
UHC Complete Care NC-27 (HMO-POS C-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
UHC Complete Care NC-25 (HMO-POS C-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Erickson Advantage Liberty (HMO-POS)	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (HMO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Dual (HMO D-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature (HMO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Value Plus (HMO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Prime (HMO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Signature Care (HMO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Full Dual Care (HMO D-SNP) via Doxy	Tier 4 - Non-Preferred	—	—	—	None
Aetna Medicare Enhanced (HMO) via Doxy	Tier 4 - Non-Preferred	—	—	—	None

NC Medicaid PDL

2 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 5 hours, 15 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC Medicaid Preferred Drug List 2026	Non-Preferred	—	—	—	None
NC Medicaid Preferred Drug List 2026 via Lymepak	Non-Preferred	—	—	—	None

NC State Health Plan

3 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 5 hours, 15 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - HDHP 2026	Not Covered	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026	Not Covered	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026	Not Covered	—	—	—	None

TRICARE

1 plan

Source: Excel (XLSX) · Formulary date: Jan 5, 2026 · Checked: 5 hours, 15 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 1 - Basic Core Formulary	✓	—	—	PA

UnitedHealthcare

1 plan

Source: PDF · Formulary date: Jan 1, 2026 · Checked: 5 hours, 15 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
UnitedHealthcare NC Individual & Family 2026	Tier 2 - Lower Cost	—	—	—	None