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; Doxycycline Hyclate Oral Capsule Doxycycline Hyclate Oral Tablet

Compare Prices

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: 3 hours, 57 minutes ago

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

AmeriHealth Caritas NC

10 plans

Source: CMS QHP JSON · Checked: 3 hours, 57 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
AmeriHealth Caritas Next Silver Essential + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Essential + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Signature + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Signature + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Signature + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Bronze Premier + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Premier + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Gold Premier + No Referrals	Tier 2 - Generic	—	—	—	None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals	Tier 2 - Generic	—	—	—	None

Blue Cross Blue Shield Federal

3 plans

Source: PDF · Formulary date: Aug 7, 2026 · Checked: 3 hours, 57 minutes ago

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

Blue Cross Blue Shield of NC

10 plans

Source: PDF · Formulary date: Aug 1, 2026 · Checked: 3 hours, 57 minutes ago

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

Cigna

20 plans

Source: PDF · Formulary date: Aug 21, 2026 · Checked: 3 hours, 57 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Connect Bronze 6500 Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 5500 Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 4400 Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3500 Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver 3000 Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Silver	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze 7000 HSA Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 2200 Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 3500 Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect Silver RD 5000 Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 6000 Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect myDiabetesCare Bronze	Tier 1 - Preferred Generic	—	—	—	None
Connect Gold 1500 Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect Bronze RD 5000 Indiv Med Deductible	Tier 1 - Preferred Generic	—	—	—	None
Connect Gold CMS Standard	Tier 2 - Generic	—	—	—	None
Connect Bronze CMS Standard	Tier 2 - Generic	—	—	—	None
Connect Silver CMS Standard	Tier 2 - Generic	—	—	—	None
Connect Bronze RD CMS Standard	Tier 2 - Generic	—	—	—	None
Connect Silver RD CMS Standard	Tier 2 - Generic	—	—	—	None
Connect Gold RD CMS Standard	Tier 2 - Generic	—	—	—	None

Medicare Part D

273 plans

Source: CMS QHP JSON · Formulary date: Aug 19, 2026 · Checked: 3 hours, 57 minutes ago

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

NC Medicaid PDL

2 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 3 hours, 57 minutes ago

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

NC State Health Plan

3 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 3 hours, 57 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

Oscar Health

84 plans

Source: CMS QHP JSON · Checked: 3 hours, 57 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Secure \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Bronze Classic 4700 \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Silver Classic \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Silver Simple Diabetes \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Silver Simple PCP Saver \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Gold Elite Saver Plus \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Bronze Simple Diabetes \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Silver Simple Chronic Care CKM \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health	Tier 2 - Generic	—	—	—	None
AIAN Cost Share	Tier 2 - Generic	—	—	—	None
AIAN Cost Share \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Gold Classic Standard	Tier 2 - Generic	—	—	—	None
Silver Classic Standard	Tier 2 - Generic	—	—	—	None
Bronze Classic Standard	Tier 2 - Generic	—	—	—	None
Silver Simple Diabetes	Tier 2 - Generic	—	—	—	None
Gold Elite Saver Plus	Tier 2 - Generic	—	—	—	None
Silver Simple PCP Saver	Tier 2 - Generic	—	—	—	None
Bronze Classic 4700	Tier 2 - Generic	—	—	—	None
Secure	Tier 2 - Generic	—	—	—	None
Bronze Classic Standard \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus	Tier 2 - Generic	—	—	—	None
Silver Classic Standard via Doxy	Tier 2 - Generic	—	—	—	None
Gold Classic Standard via Doxy	Tier 2 - Generic	—	—	—	None
Bronze Classic Standard \| with Atrium Health via Doxy	Tier 2 - Generic	—	—	—	None
Silver Classic Standard \| with Atrium Health via Doxy	Tier 2 - Generic	—	—	—	None
Gold Classic Standard \| with Atrium Health via Doxy	Tier 2 - Generic	—	—	—	None
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Doxy	Tier 2 - Generic	—	—	—	None
Bronze Simple Chronic Care CKM \| with Atrium Health via Doxy	Tier 2 - Generic	—	—	—	None
Secure \| with Atrium Health via Doxy	Tier 2 - Generic	—	—	—	None
Silver Classic	Tier 2 - Generic	—	—	—	None
Silver Classic Standard \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Gold Classic Standard \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Bronze Simple Chronic Care CKM \| with Atrium Health	Tier 2 - Generic	—	—	—	None
Bronze Classic 4700 \| with Atrium Health via Doxy	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus \| with Atrium Health via Doxy	Tier 2 - Generic	—	—	—	None
Silver Classic \| with Atrium Health via Doxy	Tier 2 - Generic	—	—	—	None
Silver Simple Diabetes \| with Atrium Health via Doxy	Tier 2 - Generic	—	—	—	None
Silver Simple PCP Saver \| with Atrium Health via Doxy	Tier 2 - Generic	—	—	—	None
Gold Elite Saver Plus \| with Atrium Health via Doxy	Tier 2 - Generic	—	—	—	None
Bronze Simple Diabetes \| with Atrium Health via Doxy	Tier 2 - Generic	—	—	—	None
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Doxy	Tier 2 - Generic	—	—	—	None
Silver Simple Chronic Care CKM \| with Atrium Health via Doxy	Tier 2 - Generic	—	—	—	None
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Doxy	Tier 2 - Generic	—	—	—	None
AIAN Cost Share via Doxy	Tier 2 - Generic	—	—	—	None
AIAN Cost Share \| with Atrium Health via Doxy	Tier 2 - Generic	—	—	—	None
Bronze Elite + PCP Saver Plus via Doxy	Tier 2 - Generic	—	—	—	None
Silver Classic via Doxy	Tier 2 - Generic	—	—	—	None
Secure via Doxy	Tier 2 - Generic	—	—	—	None
Bronze Classic 4700 via Doxy	Tier 2 - Generic	—	—	—	None
Silver Simple PCP Saver via Doxy	Tier 2 - Generic	—	—	—	None
Gold Elite Saver Plus via Doxy	Tier 2 - Generic	—	—	—	None
Silver Simple Diabetes via Doxy	Tier 2 - Generic	—	—	—	None
Bronze Classic Standard via Doxy	Tier 2 - Generic	—	—	—	None
Bronze Simple Diabetes \| with Atrium Health via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Silver Classic via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Secure via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Bronze Classic 4700 via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Bronze Classic Standard \| with Atrium Health via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Silver Classic Standard \| with Atrium Health via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Gold Classic Standard \| with Atrium Health via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Bronze Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Bronze Simple Chronic Care CKM \| with Atrium Health via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Secure \| with Atrium Health via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Bronze Classic 4700 \| with Atrium Health via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Bronze Elite + PCP Saver Plus \| with Atrium Health via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Silver Classic \| with Atrium Health via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Diabetes \| with Atrium Health via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple PCP Saver \| with Atrium Health via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Gold Elite Saver Plus \| with Atrium Health via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Bronze Elite + PCP Saver Plus via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Breathe Easy with Enhanced COPD Benefits \| with Atrium Health via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Chronic Care CKM \| with Atrium Health via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Women's Health with Menopause Benefits \| with Atrium Health via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
AIAN Cost Share via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
AIAN Cost Share \| with Atrium Health via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple PCP Saver via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Gold Elite Saver Plus via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Silver Simple Diabetes via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Bronze Classic Standard via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Silver Classic Standard via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None
Gold Classic Standard via Vibramycin	Tier 4 - Non-Preferred	—	—	—	None

TRICARE

1 plan

Source: Excel (XLSX) · Formulary date: Jul 31, 2026 · Checked: 3 hours, 57 minutes ago

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

UnitedHealthcare

17 plans

Source: PDF · Formulary date: Aug 25, 2026 · Checked: 3 hours, 57 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
UHC Silver Standard (No Referrals)	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Standard (No Referrals)	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Value ($0 Virtual Urgent Care, No Referrals)	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Standard+ Dental + Vision (No Referrals)	Tier 1 - Preferred Generic	—	—	—	None
54332NC0060010	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)	Tier 1 - Preferred Generic	—	—	—	None
54332NC0060009	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Standard (No Referrals)	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals)	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)	Tier 1 - Preferred Generic	—	—	—	None
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals)	Tier 1 - Preferred Generic	—	—	—	None
54332NC0060008	Tier 1 - Preferred Generic	—	—	—	None
54332NC0030042	Tier 1 - Preferred Generic	—	—	—	None
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals)	Tier 1 - Preferred Generic	—	—	—	None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals)	Tier 1 - Preferred Generic	—	—	—	None