doxycycline monohydrate
Generic: Mondoxyne
50 mg, 75 mg, 100 mg, 150 mg — Capsule
Also known as:
doxycycline monohydrate cap 50 mg, 100 mg
doxycycline monohydrate tab 50 mg, 75 mg, 100 mg, 150 mg
Doxycycline Monohydrate 50 Mg Capsule
Doxycycline Monohydrate 75 Mg Capsule
Doxycycline Monohydrate 100 Mg Capsule
Doxycycline Monohydrate 150 Mg Capsule
Doxycycline Monohydrate 50 Mg Tablet
Doxycycline Monohydrate 75 Mg Tablet
Doxycycline Monohydrate 100 Mg Tablet
Doxycycline Monohydrate 150 Mg Tablet
MONDOXYNE NL
ORACEA
DOXYCYCLINE IR-DR
AVIDOXY
Doxycycline Monohydrate Caps 75mg
Doxycycline Monohydrate Oral Capsule
Doxycycline Monohydrate 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.
Ambetter (Centene)
58 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
Standard Expanded Bronze with Atrium Health + Vision + Adult Dental
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Elite Bronze with Atrium Health + Vision + Adult Dental
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Everyday Bronze with Atrium Health + Vision + Adult Dental
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Elite Bronze + Vision + Adult Dental
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Everyday Bronze + Vision + Adult Dental
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Silver + Vision + Adult Dental
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Complete Gold + Vision + Adult Dental
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Focused Silver with Atrium Health + Vision + Adult Dental
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Complete Gold with Atrium Health + Vision + Adult Dental
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Expanded Bronze + Vision + Adult Dental
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Expanded Bronze with Atrium Health
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Enhanced Asthma/COPD Care Silver with $0 Drug Options
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Complete Gold
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
| Standard Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Silver + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Complete Gold with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Focused Silver with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Elite Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Complete Gold + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental | Tier 2 - Generic | — | — | — | None |
| Standard Gold with Atrium Health | Tier 2 - Generic | — | — | — | None |
|
Elite Bronze
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Clear Silver with $0 Insulin Options
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Expanded Bronze
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Silver
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Gold
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Everyday Bronze with Atrium Health
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
| Standard Silver with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Complete Gold with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Focused Silver with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Elite Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze with Atrium Health | Tier 2 - Generic | — | — | — | None |
| Standard Gold | Tier 2 - Generic | — | — | — | None |
| Standard Silver | Tier 2 - Generic | — | — | — | None |
| Standard Expanded Bronze | Tier 2 - Generic | — | — | — | None |
| Clear Silver with $0 Insulin Options | Tier 2 - Generic | — | — | — | None |
| Elite Bronze | Tier 2 - Generic | — | — | — | None |
| Everyday Bronze | Tier 2 - Generic | — | — | — | None |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options | Tier 2 - Generic | — | — | — | None |
| Complete Gold | Tier 2 - Generic | — | — | — | None |
|
Standard Silver with Atrium Health
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Gold with Atrium Health
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Gold with Atrium Health + Vision + Adult Dental
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Gold + Vision + Adult Dental
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Everyday Bronze
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Elite Bronze with Atrium Health
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Focused Silver with Atrium Health
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Complete Gold with Atrium Health
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
|
Standard Silver with Atrium Health + Vision + Adult Dental
via Mondoxyne |
Tier 2 - Generic | — | — | ✓ | QL |
AmeriHealth Caritas NC
10 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Bronze Signature + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Essential + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver 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 Bronze 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 of NC
5 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| 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 Value 2026 | Tier 1 - Lowest Cost Generic | — | — | — | None |
| BCBSNC Blue Local 2026 | Tier 1 - Lowest Cost Generic | — | — | — | None |
Cigna
20 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
Connect Gold CMS Standard
via Mondoxyne Nl |
Tier 2 - Generic | — | — | — | None |
|
Connect Silver 3000 Indiv Med Deductible
via Mondoxyne Nl |
Tier 2 - Generic | — | — | — | None |
|
Connect Silver RD 5000 Indiv Med Deductible
via Mondoxyne Nl |
Tier 2 - Generic | — | — | — | None |
|
Connect Silver 4400 Indiv Med Deductible
via Mondoxyne Nl |
Tier 2 - Generic | — | — | — | None |
|
Connect Bronze 7000 HSA Indiv Med Deductible
via Mondoxyne Nl |
Tier 2 - Generic | — | — | — | None |
|
Connect Silver RD 3500 Indiv Med Deductible
via Mondoxyne Nl |
Tier 2 - Generic | — | — | — | None |
|
Connect Bronze RD 5000 Indiv Med Deductible
via Mondoxyne Nl |
Tier 2 - Generic | — | — | — | None |
|
Connect Silver 3500 Indiv Med Deductible
via Mondoxyne Nl |
Tier 2 - Generic | — | — | — | None |
|
Connect Bronze RD 6000 Indiv Med Deductible
via Mondoxyne Nl |
Tier 2 - Generic | — | — | — | None |
|
Connect Bronze 5500 Indiv Med Deductible
via Mondoxyne Nl |
Tier 2 - Generic | — | — | — | None |
|
Connect myDiabetesCare Bronze
via Mondoxyne Nl |
Tier 2 - Generic | — | — | — | None |
|
Connect Gold 1500 Indiv Med Deductible
via Mondoxyne Nl |
Tier 2 - Generic | — | — | — | None |
|
Connect Silver RD 2200 Indiv Med Deductible
via Mondoxyne Nl |
Tier 2 - Generic | — | — | — | None |
|
Connect myDiabetesCare Silver
via Mondoxyne Nl |
Tier 2 - Generic | — | — | — | None |
|
Connect Bronze RD CMS Standard
via Mondoxyne Nl |
Tier 2 - Generic | — | — | — | None |
|
Connect Gold RD CMS Standard
via Mondoxyne Nl |
Tier 2 - Generic | — | — | — | None |
|
Connect Bronze CMS Standard
via Mondoxyne Nl |
Tier 2 - Generic | — | — | — | None |
|
Connect Silver RD CMS Standard
via Mondoxyne Nl |
Tier 2 - Generic | — | — | — | None |
|
Connect Silver CMS Standard
via Mondoxyne Nl |
Tier 2 - Generic | — | — | — | None |
|
Connect Bronze 6500 Indiv Med Deductible
via Mondoxyne Nl |
Tier 2 - Generic | — | — | — | None |
Medicare Part D
140 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| PruittHealth Premier (HMO I-SNP) | 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 |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| Troy Medicare (HMO) | Tier 1 - Preferred Generic | — | — | — | None |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| AmeriHealth Caritas VIP Care (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 |
| Senior Care (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | — | None |
| HumanaChoice H5525-050 (PPO) | Tier 2 - Generic | — | — | — | None |
| Humana Dual Select H5525-072 (PPO D-SNP) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice H5525-083 (PPO) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H6622-025 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H6622-026 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Dual Select H6622-027 (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H6622-057 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H6622-060 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H6622-061 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Choice H8145-004 (PFFS) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus - Diabetes and Heart (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 004 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE 005 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 006 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE 008 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| Wellcare Simple Open (PPO) | Tier 2 - Generic | — | — | — | None |
| Wellcare Simple (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Wellcare Giveback Open (PPO) | Tier 2 - Generic | — | — | — | None |
| Blue Medicare PPO Enhanced (PPO) | Tier 2 - Generic | — | — | — | None |
| Blue Medicare Essential Plus (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Blue Medicare Enhanced (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Blue Medicare Choice (HMO) | Tier 2 - Generic | — | — | — | None |
| Blue Medicare Essential (HMO) | Tier 2 - Generic | — | — | — | None |
| Experience Health Medicare Advantage (HMO) | Tier 2 - Generic | — | — | — | None |
| Healthy Blue + Medicare (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| Alignment Health Platinum (HMO) | Tier 2 - Generic | — | — | — | None |
| Alignment Health NC Duals (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| Alignment Health smartHMO (HMO) | Tier 2 - Generic | — | — | — | None |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 2 - Generic | — | — | — | None |
| Alignment Health Platinum Select (HMO) | Tier 2 - Generic | — | — | — | None |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Alignment Health AVA (PPO) | Tier 2 - Generic | — | — | — | None |
| HealthTeam Advantage Plan I (PPO) | Tier 2 - Generic | — | — | — | None |
| HealthTeam Advantage Plan II (PPO) | Tier 2 - Generic | — | — | — | None |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 2 - Generic | — | — | — | None |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Wellcare Dual Access (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| Wellcare Dual Liberty Open (PPO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Wellcare Assist Open (PPO) | Tier 2 - Generic | — | — | — | None |
| Wellcare Dual Liberty (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| Wellcare Dual Reserve (HMO-POS D-SNP) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H1036-137 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H1036-233 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Dual Select H1036-307 (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus Giveback H1036-318 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Humana Gold Plus H1036-335 (HMO-POS) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice H5216-211 (PPO) | Tier 2 - Generic | — | — | — | None |
| Humana Full Access H5525-034 (PPO) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice Giveback H5525-035 (PPO) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice SNP-DE H5525-036 (PPO D-SNP) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice H5525-049 (PPO) | Tier 2 - Generic | — | — | — | None |
| HumanaChoice H5525-070 (PPO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature (HMO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Dual (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature (HMO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Value Plus (HMO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Prime (HMO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature Care (HMO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Full Dual Care (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Enhanced (HMO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Enhanced (PPO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Enhanced (PPO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature Extra (PPO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature Giveback (PPO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Signature (PPO) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Chronic Care (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED DUAL FULL 013 NC (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED DUAL PLUS 006 NC (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED DUAL 009 NC (HMO D-SNP) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CORE 001 NC (HMO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED GIVEBACK 002 NC (HMO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE 001 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE GIVEBACK 002 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| DEVOTED CHOICE 003 NC (PPO) | Tier 2 - Generic | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0016 (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| UHC Complete Care NC-28 (HMO-POS C-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| UHC Complete Care NC-27 (HMO-POS C-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0007 (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0001 (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| AARP Medicare Advantage Access from UHC NC-23 (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0022 (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0021 (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0019 (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0017 (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| Erickson Advantage Champion (HMO-POS C-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| UHC Dual Complete NC-S001 (PPO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0015 (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| UHC Dual Complete NC-V001 (HMO-POS D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0012 (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthSpring TotalCare (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0011 (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0009 (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0008 (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| UHC Dual Complete NC-D001 (HMO-POS D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| UHC Dual Complete NC-S2 (PPO D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| AARP Medicare Advantage from UHC NC-0004 (PPO) | Tier 3 - Preferred Brand | — | — | — | None |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| Erickson Advantage Liberty (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| Erickson Advantage Freedom (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| Erickson Advantage Signature (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 3 - Preferred Brand | — | — | — | None |
| UHC Dual Complete NC-S3 (HMO-POS D-SNP) | Tier 3 - Preferred Brand | — | — | — | None |
| HealthSpring Preferred Savings (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| HealthSpring Preferred Select (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| HealthSpring True Choice (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
| HealthSpring Preferred (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| HealthSpring Preferred Plus (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
NC State Health Plan
6 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
NC State Health Plan - HDHP 2026
via Mondoxyne Nl |
Tier 1 - Preferred Generic | — | — | — | None |
|
NC State Health Plan - 80/20 Plus PPO 2026
via Mondoxyne Nl |
Tier 1 - Preferred Generic | — | — | — | None |
|
NC State Health Plan - 70/30 Standard PPO 2026
via Mondoxyne Nl |
Tier 1 - Preferred Generic | — | — | — | None |
| NC State Health Plan - 80/20 Plus PPO 2026 | Not Covered | — | — | — | None |
| NC State Health Plan - HDHP 2026 | Not Covered | — | — | — | None |
| NC State Health Plan - 70/30 Standard PPO 2026 | Not Covered | — | — | — | None |
Oscar Health
28 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Silver Classic Standard | Tier 2 - Generic | — | — | — | None |
| Gold Elite Saver Plus | Tier 2 - Generic | — | — | — | None |
| Silver Simple Diabetes | Tier 2 - Generic | — | — | — | None |
| 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 |
| 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 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 |
| Bronze Classic Standard | Tier 2 - Generic | — | — | — | None |
| Gold Classic Standard | Tier 2 - Generic | — | — | — | None |
| Bronze Classic Standard | with Atrium Health | 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 Elite + PCP Saver Plus | Tier 2 - Generic | — | — | — | None |
| Silver Classic | Tier 2 - Generic | — | — | — | None |
| Secure | Tier 2 - Generic | — | — | — | None |
| Bronze Classic 4700 | Tier 2 - Generic | — | — | — | None |
| Silver Simple PCP Saver | Tier 2 - Generic | — | — | — | None |
| Gold Elite Saver Plus | with Atrium Health | Tier 2 - Generic | — | — | — | None |
TRICARE
1 planUnitedHealthcare
13 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| UHC Bronze Essential ($0 Virtual Urgent Care, 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 Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, 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 Bronze Standard+ 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 |
| UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Bronze Standard (No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |
| UHC Gold 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 Standard (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 Silver Value ($0 Virtual Urgent Care, No Referrals) | Tier 1 - Preferred Generic | — | — | — | None |