doxycycline hyclate

Generic: Doxy

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

TETRACYCLINES

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
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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: 13 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Complete Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Standard Silver + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Standard Gold + Vision + Adult Dental 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
Standard Gold Tier 2 - Generic — — ✓ QL
Everyday Bronze with Atrium Health Tier 2 - Generic — — ✓ QL
Standard Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Everyday Bronze Tier 2 - Generic — — ✓ QL
Complete Gold Tier 2 - Generic — — ✓ QL
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health 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
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
Everyday Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Elite Bronze with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Focused Silver with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Standard Expanded Bronze + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Enhanced Asthma/COPD Care Silver with $0 Drug Options Tier 2 - Generic — — ✓ QL
Standard Gold with Atrium Health + Vision + Adult Dental Tier 2 - Generic — — ✓ QL
Elite Bronze Tier 2 - Generic — — ✓ QL
Source: CMS QHP JSON  ·  Checked: 13 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Gold Premier + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Premier + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Signature + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Gold Signature + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Essential + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Essential + No Referrals Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Signature + No Referrals Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 13 hours, 49 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: Jul 1, 2026  ·  Checked: 13 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Local 2026 Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Value 2026 Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Care 2026 Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Advantage 2026 Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 1 - Lowest Cost Generic — — — None
BCBSNC Blue Local 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
BCBSNC Blue Home with UNC Health Alliance 2026
via Vibramycin 		Tier 2 - Medium Cost Generic/Brand — — — None
BCBSNC Blue Value 2026
via Vibramycin 		Tier 2 - Medium Cost Generic/Brand — — — None
Source: PDF  ·  Formulary date: Jan 1, 2026  ·  Checked: 13 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver RD 3500 Indiv Med Deductible Tier 1 - Preferred Generic — — — None
Connect Bronze 6500 Indiv Med Deductible Tier 1 - Preferred Generic — — — None
Connect myDiabetesCare Silver Tier 1 - Preferred Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 1 - Preferred Generic — — — None
Connect Gold 1500 Indiv Med Deductible Tier 1 - Preferred Generic — — — None
Connect myDiabetesCare Bronze Tier 1 - Preferred Generic — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 1 - Preferred Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible Tier 1 - Preferred Generic — — — None
Connect Silver 3500 Indiv Med Deductible Tier 1 - Preferred Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible Tier 1 - Preferred Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible Tier 1 - Preferred Generic — — — None
Connect Silver 4400 Indiv Med Deductible Tier 1 - Preferred Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible Tier 1 - Preferred Generic — — — None
Connect Silver 3000 Indiv Med Deductible Tier 1 - Preferred Generic — — — None
Connect Gold RD CMS Standard Tier 2 - Generic — — — None
Connect Bronze CMS Standard Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard Tier 2 - Generic — — — None
Connect Silver CMS Standard Tier 2 - Generic — — — None
Connect Silver RD CMS Standard Tier 2 - Generic — — — None
Connect Gold CMS Standard Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 13 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
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
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic — — — None
PruittHealth Premier (HMO I-SNP)
via Doxy 		Tier 1 - Preferred Generic — — — None
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
Longevity Health Plan (HMO I-SNP)
via Doxy 		Tier 1 - Preferred Generic ✓ — — PA
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — — PA
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — — — None
Troy Medicare (HMO) 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
Wellcare Giveback Open (PPO) Tier 2 - Generic — — — None
Wellcare Giveback Open (PPO)
via Doxy 		Tier 2 - Generic — — — None
Wellcare Simple (HMO-POS) Tier 2 - Generic — — — None
Wellcare Simple Open (PPO) Tier 2 - Generic — — — None
Wellcare Simple (HMO-POS)
via Doxy 		Tier 2 - Generic — — — None
Wellcare Simple Open (PPO)
via Doxy 		Tier 2 - Generic — — — None
Liberty Medicare Advantage (HMO C-SNP) Tier 2 - Generic — — — None
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic — — — None
Senior Care (HMO I-SNP) Tier 2 - Generic — — — None
Senior Care (HMO I-SNP)
via Doxy 		Tier 2 - Generic — — — None
Liberty Medicare Advantage (HMO C-SNP)
via Doxy 		Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic — — — None
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Doxy 		Tier 2 - Generic — — — None
Humana Full Access H5525-034 (PPO) 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 Plus H1036-335 (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 Giveback H1036-318 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Dual Select H1036-307 (HMO D-SNP) 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
Humana Gold Plus H1036-233 (HMO-POS) Tier 3 - Preferred Brand — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) 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
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
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
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
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
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
Wellcare Dual Reserve (HMO-POS D-SNP)
via Doxy 		Tier 4 - Non-Preferred — — — None
Wellcare Dual Reserve (HMO-POS D-SNP) Tier 4 - Non-Preferred — — — None
Humana Gold Plus SNP-DE H1036-331 (HMO 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
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
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
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
AARP Medicare Advantage from UHC NC-26 (HMO-POS)
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 Freedom (HMO-POS)
via Doxy 		Tier 4 - Non-Preferred — — — None
Erickson Advantage Liberty (HMO-POS)
via Doxy 		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
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
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
AARP Medicare Advantage from UHC NC-26 (HMO-POS) 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 Freedom (HMO-POS) Tier 4 - Non-Preferred — — — None
Erickson Advantage Liberty (HMO-POS) Tier 4 - Non-Preferred — — — None
UHC Complete Care NC-25 (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-28 (HMO-POS C-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
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
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
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
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
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 Giveback H1036-318 (HMO-POS)
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
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 13 hours, 49 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
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 13 hours, 49 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
Source: CMS QHP JSON  ·  Checked: 13 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Bronze Elite + PCP Saver Plus Tier 2 - Generic — — — None
Silver Classic Standard
via Doxy 		Tier 2 - Generic — — — None
Bronze Classic Standard
via Doxy 		Tier 2 - Generic — — — None
AIAN Cost Share | with Atrium Health Tier 2 - Generic — — — None
AIAN Cost Share Tier 2 - Generic — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 2 - Generic — — — None
Silver Simple Chronic Care CKM | with Atrium Health Tier 2 - Generic — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 2 - Generic — — — None
Bronze Simple Diabetes | with Atrium Health Tier 2 - Generic — — — None
Bronze Simple Chronic Care CKM | with Atrium Health Tier 2 - Generic — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 2 - Generic — — — None
Gold Elite Saver Plus | with Atrium Health Tier 2 - Generic — — — None
Gold Classic Standard | with Atrium Health Tier 2 - Generic — — — None
Silver Classic Standard | with Atrium Health Tier 2 - Generic — — — None
Bronze Classic Standard | 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 PCP Saver | with Atrium Health Tier 2 - Generic — — — None
Silver Simple Diabetes | with Atrium Health Tier 2 - Generic — — — None
Silver Classic | with Atrium Health Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 2 - Generic — — — None
Bronze Classic 4700 | with Atrium Health Tier 2 - Generic — — — None
Secure | with Atrium Health 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
Silver Classic 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 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
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
Silver Simple Diabetes | with Atrium Health
via Doxy 		Tier 2 - Generic — — — None
Silver Classic | with Atrium Health
via Doxy 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health
via Doxy 		Tier 2 - Generic — — — None
Bronze Classic 4700 | with Atrium Health
via Doxy 		Tier 2 - Generic — — — None
Secure | with Atrium Health
via Doxy 		Tier 2 - Generic — — — None
Silver Simple Diabetes
via Doxy 		Tier 2 - Generic — — — None
Gold Elite Saver Plus
via Doxy 		Tier 2 - Generic — — — None
Silver Simple PCP Saver
via Doxy 		Tier 2 - Generic — — — None
Bronze Classic 4700
via Doxy 		Tier 2 - Generic — — — None
Secure
via Doxy 		Tier 2 - Generic — — — None
Silver Classic
via Doxy 		Tier 2 - Generic — — — None
Bronze Elite + PCP Saver Plus
via Doxy 		Tier 2 - Generic — — — None
Gold Classic Standard | with Atrium Health
via Doxy 		Tier 2 - Generic — — — None
Silver Classic Standard | with Atrium Health
via Doxy 		Tier 2 - Generic — — — None
Bronze Classic Standard | with Atrium Health
via Doxy 		Tier 2 - Generic — — — None
Gold Classic Standard
via Doxy 		Tier 2 - Generic — — — None
AIAN Cost Share | 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 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
Bronze Simple Diabetes | with Atrium Health
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
Silver Simple Diabetes | with Atrium Health
via Vibramycin 		Tier 4 - Non-Preferred — — — None
Silver Classic | 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
Bronze Classic 4700 | with Atrium Health
via Vibramycin 		Tier 4 - Non-Preferred — — — None
Secure | with Atrium Health
via Vibramycin 		Tier 4 - Non-Preferred — — — None
Silver Simple Diabetes
via Vibramycin 		Tier 4 - Non-Preferred — — — None
Gold Elite Saver Plus
via Vibramycin 		Tier 4 - Non-Preferred — — — None
Bronze Classic 4700
via Vibramycin 		Tier 4 - Non-Preferred — — — None
Silver Simple PCP Saver
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
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 Elite + PCP Saver Plus
via Vibramycin 		Tier 4 - Non-Preferred — — — None
Silver Classic
via Vibramycin 		Tier 4 - Non-Preferred — — — None
Secure
via Vibramycin 		Tier 4 - Non-Preferred — — — None
Source: Excel (XLSX)  ·  Formulary date: Jun 24, 2026  ·  Checked: 13 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026 Tier 1 - Basic Core Formulary ✓ — — PA
Source: PDF  ·  Formulary date: Jun 23, 2026  ·  Checked: 13 hours, 49 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Silver Standard (No Referrals) 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
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, No Referrals) Tier 1 - Preferred Generic — — — None
UHC Gold Standard (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
UHC Bronze Standard+ Dental + Vision (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 Bronze Essential ($0 Virtual Urgent Care, No Referrals Tier 1 - Preferred Generic — — — None
UHC Bronze Standard (No Referrals) Tier 1 - Preferred Generic — — — None
UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, 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
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